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7' 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 

MRS.  PRUDENCE  W.  KOFOID 


THE  CRYSTALLINE 
LENS  SYSTEM. 


ts  Enibryology,  Anatomy,  PhysiblQgical  Chemistry, 
Physiology,  Pathology,  Diseases,  Treatment, 
Operations  and  After-Changes  •  With 
a  Consideration  of  Aphakia* 


BY 

LOUIS   STRICKER,  M.  D. 

CINCINNATI,  O. 


1899 


Copyright  October  24,  189J 

BY 

LOUIS   STRICKER.  M.  D. 


fj^^ 


■-*yv-- 


UBAW 


THIS   BOOK   IS   DEDICATED 


ro  THE  MEMORY  OK 


OTTO   BECKER. 

The  Inspiration  of  this  Worl<  is  the  Fruit  of  His  Labor. 


ivi35J:G51 


TABLE  OF  CONTENTS. 


THE  CKYSTALLINE  LENS  SYSTEM. 


INTRODUCTIOX— GENERAL  CONSIDERATION. 

PART  I. 

THE  NORMAL  LENS  SYSTEM. 

CHAPTER   I. 

THE  DEVELOPMENT  OF  THE  LENS  SYSTEM. 

First  Period  of  Development. 
Second  Period  of  Development. 
Third  Period  of  Development. 
Development  of  the  Capsule  of  the  Lens. 
Development  of  the  Zonula  of  Zinn. 

CHAPTER   II. 

THE  GROWTH  OF  THE  LENS  SYSTEM. 

The  Foetal  Period  of  GroAvth. 
The  Extra  Uterine  Period  of  Growth. 

The  manner  in  which  the  fibres  adhere  to  the  Epithelium,  also  at  the  Pos- 
terior Capsule;  the  formation  of  new  Lens  Fibres. 
The  growth  of  (a)  the  Capsule  of  the  Lens; 
(h)  The  Zonula  of  Zinn. 

CHAPTER   III. 

THE   PHYSIOLOGICAL   RETROGRESSION   OF   THE   LENS   AND 
ITS  ELEMENTS. 

Death  of  the  Nuclei  in  the  Lens  Fibres. 

Physical  changes  in  the  Lens  Fibres. 

Changes  due  to  age  occurring  in  the  Epithelium  of  the  Lens. 


CHAPTER    IV. 

THE  MAXXKlf  IX  WHICH  TIIK  XOIJMAL  AND  PATPIOLOGICAL 
LEXS-SVSTE^I  18  NOUinSHED. 

The  direction  and  course  of  tlie  Xutritive  Stream  in  the  Lens. 

The  Physical  changes  whicli  take  place  in  the  lens  with  increasing  age. 

(The  increase  and  reduction  in  volume). 
The  Chemistry  of  the  Lens  and  its  surrounding  fluids.     (The  chemically 

demonstratable   difference   which    exist   between   the   nucleus   of   the 

senile  noncloudy  and  the  senile  cataractous  Lens). 


PART  II. 

THE  PATHOLOGICAL  LENS  SYSTEM. 

CHAPTER   I. 

THE  PATHOLOGY  OF  THE  ZONULA  OF  ZINN. 

Atrophy,  Hypertrophy.  Dissolution,  Anomalies  of  Formation.     Solution  of 
Continuity. 

CHAPTER   II. 

THE  PATHOLOGICAL  CHANGES  IX  THE  LENS.     LENTICULATJ 

CATAEACT. 

Senile  Cataract. 

Cataract  formation  in  Youthful  Lenses. 

CHAPTER   III. 

THE    PATHOLOGICAL    CHANGES    IN    THE    IXTKACAPSULAK 
CELLS— CAPSULAR  CATARACT. 

The  degenerative  changes. 

The  new  cellular  formations  which  develu})  from  the  intracapsular  cells. 

a.  Regenerative  New  Cellular  Formations. 

h.  The  processes  and  products  of  Atrophic  New  Cellular  Formations. 

L  E])ithelial  covering  of  tlie  posterior  capsule. 

'I.  Wedl's  Vescicular  Cells. 

3.  Capsular  Cataracts,  {a)  Capsular  Cicatrices. 

{h)  True  capsular  Cataract. 

4.  Enclosure  of  foreign  substances. 

5.  Formation  of  Pus  in  tlie  Lens. 


CIIAI'TER    IV. 
THE    flKXKI{AL    PATIlOLOdV    AND    I'A'IIIOC  KX  K.SIS    OF    THE 

LKNS. 

A.  The  Progressive  i'liaiu/cs  in  Hip  Lens. 

1.  Causes  of  the  abnormal  ct'llular  formations  in  Senile  Cataract. 

2.  Causes  of  the  abnormal  formations  in  Consecutive  Cataract. 

(1.  Constitutional  Cataract.    Catarada   Diabetica 
b.  Consecutive  Partial  Cat.  Anterior  Polar  Cat- 
aract. 
Inflammatorv  capsular  cloudiness. 
Kegenerative  Cellular  Hyperplasia. 
Restricted  growth  of  Capsular  Cataract. 

B.  The  Hetruijressive  Changes  in  the  Lens. 
1.  In  the  Lens  Fibres. 

3.  In  the  Intracapsular  Cells. 


PART  III. 

A  SYSTEMATIC    COXSIDERATIOX    OF    THE    CAUSES    AND    A 

CLINICAL  DESCRIPTIOX  OF  ALL  OF  THE  DISEASES 

OF  THE  CRYSTALLINE  LENS. 

CHAPTER   I. 

A     GENERAL     CONSIDERATION     OF     THE      ANOMALIES     OF 
TRANSPARENCY.     THE  GREY  CATARACT. 

General.     (Definition,    nanie.    division,    aetiology,    diagnosis,    symptoma- 
tology.) 

Historical  Review  of  the  correct  recognition  of  the  Grey  C'ataract,  and  of 
the  expression  "Catarakta." 

Cataracta  and  "Staar";  Spuria  and  Vera. 

The  varieties  of  Cataract. 

The  diagnostic  features  of  Cataract,     a.  Objective  Symptoms. 

b.  Subjective  Symptoms. 

The  Quantitative  and  Qualitative  Sensation  to  light. 

Examination  of  the  Field  of  Vision. 

Aetiology  of  Cataract. 

CHAPTER    n. 

MALFORMATIONS  OF  THE  LENS  SYSTEM  WHICH  ARE  ASSO- 
CIATED WITH  ANOMALIES  OF  THE  HYALOID  ARTERY 
OR  THE  VASCULAR  CAPSULE  OF  THE  LENS. 

Conditions  of  the  lens  in  eases  of  anopthalmus  and  mieropthalmus. 

Two  distinct  Lens  systems  in  a  single  cyclopic  eye. 

Cataracta  membranacea  congenita  accreta. 

Cataracta  polaris  posterior  supria.  I 


8 

CHAPTER   III. 

MALFORI^fATIONS  OF  THE  LEX8  SVSTE]\I  IX  C'OXSEQUEXCE  OF 
UXSYMMETEICAL  DEVELOPMEXT  OF  THE  ZOXULA 

FIBRES. 

Coloboma  Lentis. 
Ectopia  Lentis. 

CHAPTER   TV. 

ACQUIRED  ANOMALIES  OF  POSITION  NOT  DUE  TO  MALFOR- 
MATIONS.    LUXATIO  LENTIS. 

Spontaneous  Luxation.  1.  Normal  Lens.    ^'Synchisis  corporis  vitrei.^* 

2.  Caitaractons  Lenses. 
Tranmatic  Lnxation.         a.     1.  Causation. 

2.  (Sympathetic  Optlwlmia.) 

3.  S3aiiptoms. 
h.  Subluxation. 

c.  Total  Luxation. 

d.  Freely  Moveable  Lenses  (Results  of  Luxation). 


Secondary  Luxation. 


CHAPTER   V. 


MALFORMATION  OF  THE  LEXS  WITHOUT  DEMONSTRATABLE 
PATHOLOGMCAL  CHANGES  IN  OTHER  PORTIONS  OP  THE 
EYE. 
Indented  or  Notched  Lens. 
Lenticonus-Krystaloconus.     a.  Anterior. 
/;.  Posterior. 

CHAPTER   VI. 

PARTIAL  CATARACTS. 

A.  Axial  Cataracts.     (Cataracta  Axialis). 

1.  Cataracta  Centralis.    Congenital  central  lens  cataract. 

2.  Cataracta  Polaris  Anterior.  Cataracta  polaris  pyramidalis. 

a.  Congenita. 

h.  Acquisita. 

c.  Cataracta  Capsularis  Anterior. 

3.  Cataracta  Polaris  Posterior.     Vera. 

4.  Cataracta  Fusiforrais — Spindle  Cataract. 

B.  Zonular  Cataract — Ijaniellar. — Cataracta  Zonularis. 

C.  A^ariou.s  forms  of  congenital  ])artial  cataracts. 

a.  Cataracta  Punctata. 
h.  Cataracta  Stellata. 


CHAPTER  VII. 

COMPLICATED  CATARACTS.       CATARACT  A  ACCRETA.       CAT- 

ARACTA  CO:\irLICATA. 
Casuistik. 

Calcifications  of  the  Lens.     Cataracta  oalcarea. 
Ossification  of  the  Lens.     Cataracta  ot^sea. 
Perforation  of  the  capsule  of  tlie  lens  a?  the  result  of  the  traction  of  cyclitic 

bands. 

CHAPTER  VIII. 

CATARACT   DUE    TO    DJSKASK   OF   ONK    KYK    WITllol'T   'I'lIK 

PRESENCE  OF  ABXOR^LVL  ADITK.'^IONS. 

Cataracta  mollis  ex  chorioiditide. 

CHAPTER  IX. 

CONSTITUTIONAL  CATARACT. 

A.  Cataracta  polaris  posterior  (Retinitis  pigmentosa). 

B.  Cataracta  Chorioidealis. 

C.  Total  congenital  cataract  on  l)oth  Eyes.     Causes  of  cataracts  of  sudden 

development. 

D.  Total  acquired  cataract  on  both  Eyes. 

a.  Cataracta  mollis  juvenum. 

b.  Cataracta  Diabetica. 

1.  Casuistik. 

2.  Manner  of  Development. 

3.  Aetiology. 

E.  Cataracta  senilis  praematura.     Cataracta  nuclearis. 

Cataracta  punctata  (see  Chapter  VI). 

F.  Cataracta  Senilis — Senile  Cataract.    Aetiology. 

Chronic  Nephritis. 
Carotidis  Atheroma. 

G.  Cataracta  Hypermatura.   1.    a.    Cataracta  hypermatura  reducta. 

2.    h.    Cataracta  hypermatura  fluida. 

H.  Cataracta  Nigra. 

CHAPTER  X. 

CATARACTA  CAPSULARIS.     SIMPLEX— COMPLICATA. 

CHAPTER  XI. 

PATHOLOGICAL    CONDITIONS    IN    ORIGINALLY    NOILMALLY 

FORMED  LENSES  PRODUCED  BY  EXTERNAL  FORCE. 

CATARACTA  TRAUMATICA. 

By  Blunt  Force,     a.  Cataracta  ex  Contusione. 

h.  Traumatic  Luxations,  tears  in  the  zonula  and  rupture 
of  the  capsule. 
By  Puncture  or  Incision,     c.  Unintentional    (accidental    injuries).     Cata- 
racta Traumatica. 
(/.  Intentional  (operative  secondary  cataracts). 


PARTIV. 


JL 

THE  MEMiCTDfAL  TKEATMESnT. 


ZliL  •C*E3fcATITE  TKELATMEST. 

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i::  jd3«^  ASD  AFTEB  A  <f  ATARACT  OPEBATIOX. 

z.i-'iya  44  dyes  «iii  wMA 


'j^  dnrioj^  the 


T^  >  iitJu  m^i«Mif^k!te  vKsmkii. 


Tie 

TW  asm 


•«L  B?»a«wi«-  ■«. 


_riL  ^  1^  4«IB-  JOEb 


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INTRODUCTION 


At  the  time' this  work  was  first  contemplated,  the  intention  was  to 
make  a  translation  of  Otto  Beclcer's  Palhologie  und  Therapie  des  Linsen- 
sytems,"  Graefe-Saemisch  Handlmcli,  Vol.  V.  1877,  but  as  the  work  pro- 
gressed it  became  evident 'that  many  oi'  the  ideas  therein  expressed  were  not 
in  accord  with  the  teachings  of  modern  pathology.  The  introduction  of 
more  delicate  and  accurate  methods  for  pursuing  microscopical  investiga- 
tions, the  use  of  the  refracting  opthalmoscope,  the  introduction  of  cocaine, 
the  application  of  antisepsis,  later  of  asepsis  to  eye  surgery,  have  all  added 
their  share  to  the  elucidation  of  this  subject.  No  one  who  has  carefully 
read  Becker's  great  classic  on  the  Crystalline  Lens  could  possibly  fail  to  be 
impressed  with  the  keenness  of  his  observation  and  the  clearness  and  sim- 
plicity of  his  style.  His  historical  references  are  so  accurate,  and  his  clin- 
ical pictures  so  vivid  and  concise,  that  uj)  to  the  present  time  they  have  not 
been  excelled.  In  1883  he  supplemented  this  work  by  another  classic, 
"Zur  Anatomie  der  Gesunden  und  Kranhen  Linse,^  the  results  of  further 
histological  and  pathological  investigation.  These  two  great  classics,  which 
to  the  great  majority  of  the  English-speaking  opthalmologists  are  as  a 
sealed  book,  together  with  a  most  careful  and  critical  review  of  all  that  has 
been  published  on  this  and  kindred  subjects  since  that  time,  form  the  basis 
of  this  work. 


1  Unter  mitwlrkiing  von  Dr.  J.  R.  DaGama  Pinto  und  Dr.  H.  Schafer.    Weis- 
baden,  1883. 


GENERAL  CONSIDERATION 


In  taking  up  the  study  of  the  Cri/slalliur  Lom  Si/slrin.  one  can  not 
properly  consider  the  Ci-ystalliiu'  Lcii^  witlioiil  al  the  same  tiiiu'  studying  its 
suspensory  ligainent.  Tlir  Zotnihi  of  Zimi  {/ji(/tniieiilnni  Suspensorium 
Lentis).  By  means  of  this  Hgameni  the  lens  is  suspended,  supported 
and  I'etained  in  its  proper  ichition  to  the  remaining  structures  of 
the  eye.  The  gi'eat  importance  of  this  systiMu  of  fil)i-ilhie  can  only  be 
fully  realized  after  a  careful  study  of  its  congenital  malformations,  its  con- 
dition both  in  health  and  disease,  and  its  physiological  relation  to  the  lens. 

Tlie  Zonula  of  Zinn  is  the  anatomical  medium  by  means  of  which  the 
ciliary  muscle  and  the  lens,  which  are  ivol  in  direct  contacl.  are  brought 
together.  Without  a  pei-fect  and  regulai-  (h'velopment  of  this  structure, 
perfect  power  of  accommocUition  can  not  exist,  'i'he  proper  centering  of 
the  lens  in  its  relation  to  the  coi'nea.  likewise  in  how  far  the  axis  of  the  lens 
and  the  cornea  coincide,  will  he  dependent  on  the  al)ove  fact.  The  visual 
axis  is  greatly  influenced  by  the  ])osition  of  the  lens  in  the  eye. 

The  lens  system  is  an  integral  portion  of  the  so-called  refracting  media 
of  the  eye,  and  since  the  index  of  refraction  of  the  aqueous  humour  in  front 
of  it,  and  the  vitreous  humour  behind  it,  are  both  nearly  equal  to  that  of 
distilled  water,  and  less  than  that  of  the  lens:  hence  even  in  a  physical 
sense,  the  Crystalline  Lens  is  a  lens.^  It  differs  from  the  ordinary  lens  in- 
dependent of  any  asymmeti-y  of  its  surface  in  that,  in  the  first  place,  it  is 
not  a  homogeneous  body,  but  consists  of  concentric  lamellae  which  are  most 
closely  packed  near  the  center,  and  in  the  second  ])lace  has  the  abilit}'  of 
changing  its  form  under  influence  of  Ihe  ciliai'y  body.  As  a  result  of  con- 
traction of  this  muscle,  the  lens  becomes  tiiicker,  the  radii  of  l)()th  its  .«iur- 
faces,  and  in  all  probability  thi^  e<|uatorial  dianu'ler  also  becomes  less. 
During  this  change  the  i)()slerior  pole  keeps  il>  position,  whereas  the  an- 
terior pole,  as  can  be  ])i'oven.  nears  the  cornea.  Tlie  power  of  accommoda- 
tion is  dependent  on  this  ability  of  the  lens  to  change  its  form. 

Our  more  advanced  methods  of  making  a  functional  examination  en- 
able us  to  demonstrate  changes  of  a  histological  nature,  the  senile  included, 
even  before  they  can  be  recognized  by  the  microscope.  This  is  fully  con- 
sidered in  works  on   Accommodation   and    h'efraction.      In   the   interest   of 


1  Heluiholtz's  Physiological  Optic,  p.  63. 


i6 

undisturbed  function  of  the  lens  system,  considering  only  the  physical  side 
of  the  subject,  it  is  necessary  that  the  index  of  refraction,  and  the  elasticity 
of  each  individual  fibre  should  remain  unchanged,  for  as  is  demonstrated 
by  even  the  slightest  senile  or  other  pathological  change,  they  become  mat- 
ters of  the  very  greatest  importance,  not  equaled  by  like  changes  in  any 
other  tissue  of  the  body.  As  regards  their  transparency,  the  elements  of 
the  lens,  likewise  those  of  the  cornea,  have  following  every  pathological 
change  a  cloudiness,  hence  functional  disturbances. 

In  order  that  the  lens  may  perform  its  functions  normally,  it  is  nec- 
essary that  it  should  be  transparent,  that  its  separate  parts  should  be  mov- 
able one  upon  the  other;  that  each  lamella  should  have  a  different  index  of 
refraction  regularly  increasing  toward  the  center  of  the  lens;  that  the  sur- 
face of  the  lens  should  have  an  almost  spherical  curvature,  and  be  almost 
centered  in  the  corneal  axis,  and  that  the  lens  in  its  entirety  be  freely  mov- 
able, and  be  in  no  pathological  manner  adherent  to  neighboring  structures, 
more  particularly  the  iris. 

The  lens  is  an  epitlielial  structure.  It  consists  of  the  ordinary  epith- 
elial cells,  and  so-called  lens  fibres,  which  are  simply  epithelial  cells  which, 
have  taken  on  an  extraordinary  development  and  become  elongated.  Ex- 
ternally the  lens  is  covered  by  a  structureless  membrane,  the  lens  capsule, 
which  encloses  it  completely. 

Notwithstanding  its  apparently  simply  construction,  the  study  of  its 
more  minute  structure,  and  the  various  processes  which  take  place  in  the 
lens,  has  been  connected  with  the  very  greatest  difficulties.  This  was  de- 
pendent not  only  on  the  proper  recognition  of  the  nature,  and  the  function 
of  the  individual  elements  of  the  lens,  but  here  more  than  in  any  other 
structure  of  the  body  was  the  difficulty  encountered,  of  understanding  the 
manner  in  which  the  individual  lens  fibres  are  laid  down  and  connected 
with  neighboring  fibres.  Only  after  the  embryology  of  the  lens,  had  been 
studied,  was  a  definite  and  clear  idea  of  its  architecture  and  histological 
structure  understood.  The  proper  understanding  of  the  wonderful  reg- 
ularity in  the  arrangement,  and  the  peculiar  manner  in  which  the  fibres 
are  adherent  to  each  other,  has  only  been  attained  by  a  study  of  the  devel- 
opment and  growth  of  the  foetal  lens.  The  importance  of  this  knowledge 
will  become  apparent  at  once,  when  it  is  known  that  a  dei)arture  from  this 
regular  development,  even  the  slightest  interference  with  this  absolute  con- 
nection between  the  individual  fibres,  is  followed  by  an  interference  with 
the  function  of  the  lens  as  a  transparent  body  which  refracts  the  light  in 
an  absolutely  regular  manner. 

Every  departui'c  Iroiu  the  normal  is  to  be  sought  in  an  interference 


17 

with  the  normal  devehipniont  of  the  leii^;,  or  i]i  ;iu  anomalous  growth,  as  the 
result  of  an  ahnonnal  nutrition,  or  conditions  which  persist  in  consequence 
of  an  interrupted  physiological  progression.  Hence  the  study  of  the  de- 
velopment, progression  and  growth  of  the  human  lens  are  not  only  of 
scientific  interest,  but  are  of  the  very  greatest  practical  importance. 

The  study  of  the  embryology  will  elucidate  many  of  the  seemingly 
difficult  to  understand  malformations  and  anomalies  of  position  and  at- 
tachment, and  aid  us  in  fixing  the  most  probable  time  of  the  development 
of  certain  congenital  pathological  conditions. 

The  lens  being  fully  developed,  we  shall  follow  it  through  its  period  of 
physiological  growth  and  retrogression,  note  the  changes  which  the  individ- 
ual fibres,  as  well  as  the  lens,  as  a  whole,  undergoes.  Further,  the  mode  of 
entrance  and  exit  of  the  nutritive  fluids  into  the  lens.  Lastly,  consider  the 
chemistry  of  the  lens  and  its  surrounding  fluids.  It  has  been  hoped,  and 
not  without  good  cause,  that  the  investigation  of  the  mode  of  nutrition  and 
chemistry  of  the  lens,  and  the  chemistry  of  its  surrounding  fluids,  would 
throw  some  light  on  the  aetiology  of  cataract — more  especially  the  con- 
stitutional forms  such  as  occur  in  Bright's  Disease  and  Diabetes. 

The  pathological  processes  which  play  a  part  in  the  pathology  of  the 
lens  are,  on  the  one  hand,  those  of  proliferation  and  degeneration  of  its 
intracapsular  cells;  on  the  other,  sclerosis,  separation  and  softening  of  the 
fibres  of  the  lens,  together  with  all  the  secondary  changes  which  follow 
these  conditions.  The  lens  may  secondarily  be  affected  either  as  a  result 
of  disease  of  other  structures  in  the  eye,  or  as  the  result  of  inequalities  in 
the  development  of  the  Zonula  of  Zinn,  or  as  the  result  of  pathological 
conditions  of  the  same. 

As  a  result  of  these  pathological  changes  the  full  functions  of  the  lens 
are  modified  in  the  following  manner: 

1.  The  single  lamellae  gradually  become  changed  into  a  homogene- 
ous mass  (Senile  Sclerosis).  The  refracting  power  of  the  lens  is  reduced  and 
the  far  point  is  removed  from  the  eye,  Acquired  Ifj/permetropia  (H.  Acqui- 
sita). 

2.  The  moveableness  of  the  separate  elements  and  lamellae  againsi 
each  other  is  gradually  diminished  and  finally  abolished,  at  the  same  time 
the  ability  of  the  lens,  as  a  whole,  to  change  its  shape,  becomes  gradually 
reduced  and  finally  abolished  (Senile  Sclerosis).  The  near  point  gradually 
becomes  removed  from  the  eye,  and,  as  a  consequence,  the  amplitude  of 
accommodation  more  restricted,  until  finally  there  is  an  entire  loss  of  ac- 
commodation (Presbyopia). 

3.  Though  its  form  n>m;uns  uuchanoed,  the  lens  suffers  in  its  trans- 


i8 

parency.  As  a  result,  tlifiv  i-  a  gfueial  (liiiiimttiou  in  tlie  ability  to  .seii 
accurately,  until  finally  only  a  quantitative  difference  can  be  distinguished 
on  throwing  light  into  the  eye.  This  condition  is  recognized  as  cataract, 
and  is  the  most  generally  recognized  pathological  condition  of  the  lens. 

The  various  diseases  and  pathological  conditions  of  the  crystalline  lens 
system,  the  causation  and  clinical  description  of  the  same,  the  malformations 
associated  vith  anomalief'  of  the  hijaloid  arteri/  or  the  rasnilar  capsule  of  fJie 
lens,  those  due  to  vn.si/m metrical  development  of  the  Zonnia  fibres  {Ectopia 
Lent  is);  likewise  the  acquired  anomalies  of  position  not  due  to  malforma- 
tions: (LiLvatio  Lentis)  also  the  independent  malformations  of  the  lens  will 
be  successively  taken  up.  all  of  which,  as  will  be  seen,  excepting  the  congen- 
ital, and  the  traumatic,  are  the  result  of  nutritive  disturbances.  An  altered 
chemical  constitution  of  the  nutritive  supplji  is  the  initial  step  toirard  the 
formation  of  cataract. 

The  formation  of  a  nucleus  is  a  perfectly  physiological  process,  and  no 
sharp  line  of  demarcation,  either  histological  or  in  point  of  development, 
exixst  between  the  nucleus  (Xucleus  Lentis)  and  the  cortex  of  the  lens  {Sub- 
stantia Corticalis).  An  interference  with  the  regular  sclerosis  of  the  nu- 
cleus has  been  said  to  be  the  initial  cause  of  the  development  of  senile  cat- 
aract. The  chemicaUi/  altered  fluid  which  flh  the  interspaces  between  lamellae 
gives  rise  to  an  abnormal  interchange  between  this  rheinically  altered  fluid  and 
contents  of  the  lens  fibres.  This  i7i  its  turn  leads  to  an  altered  condition  of 
the  cortex,  the  cvpression  of  which  is  an  altered  refractive  condition  and  loss 
of  transparency  which  ire  designate  as  cataract. 

These  changes  once  having  set  in,  it  is  apparent  how  useless  all  at- 
tempts at  restitution  by  thei-a]ieutic  measures  must  be. 

The  various  methods  of  removing  the  interference  with  sight  (cataract; 
will  he  successively  discussed.  It  would  be  useless  to  consider  in  detail  all 
the  minute  changes  which  the  various  operators  have  introduced;  only  such 
will  be  considered  as  have  a  general  bearing  on  the  subject,  and  which  il- 
lustrate the  fundamental  principles  on  which  the  various  methods  are  based. 

In  no  department  of  surgery  does  the  personal  equation  of  the  operator 
play  so  prominent  a  role  as  in  the  extraction  of  cataract.  Tlio  eyeball  being 
a  globe,  the  moment  it  is  incised  the  relative  position  of  its  various  struc- 
tures is  changed,  and  the  intraocular  pressure  is  alteK'd.  Further,  since  the 
successful  extraction  of  a  cataract  in  and  of  itself,  does  not  insure  a  suc- 
cessful restoration  of  sight,  the  study  of  all  those  processes  which  take  place 
during  the  period  of  healing,  and  sul)seq\i('nt  thereto,  likewise  are  of  th-.' 
very  greatest  importance.  Ht-ncc.  a  definite  uiidcrstMnding  of  all  these 
conditions  is  essential  to  the  |)i-o|t('r  management  of  tlic  iiidividnal  case. 

Finally  the  snl)jcct  of  apliakia  will  be  eonsidered. 


THE  NORMAL  LENS  SYSTEM. 


PART  I. 

CHAI'l'KU    I. 

TIIK  l)K\I-:L()l'Mi:N'r  ol-  TJIK  LKXS. 

••Td-diiv  all  iiivesti*iator.s  agree  tlial  tlu-  tir>t  dispos^ition  to  the  forma- 
tion of  tlie  lens  eonsists  in  a  thiekening  of  the  eetoflenn.  This  original 
gronp  of  cells  undergoes  an  invagination:  later  on  these  cells  are  cut  off  and 
a  hollow  vesicle  is  formed.  Kollil-er  acepts  this  mode  of  development  for 
the  cuttle  fish.  Reiuak  and  Barhiii  for  the  frog.  Iliisrld-e,  Remak.  Henle 
and  J I  Is  for  tli^  chick,  and  Kessler  and  KoUik-er  for  mammals."* 

••Hi>'  accepts  this  involution  of  an  open  vesicle  in  the  formation  of 
the  lens  in  the  human  einbrvo.  and  >o  illustrates  it.  Kessler  agrees  with 
him,  having  had  the  opportunity  i)f  examining  a  human  embryo  expelled 
three  weeks  after  the  last  menstruation,  and  with  a  loup  he  observed  in 
this  the  funnel  shaped  involution.  Bambeke^  states  that  in  an  embryo  in 
the  fourth  week,  which  lie  examined,  he  found  the  lens  still  connected  with 
the  cuticular  epiblast.  by  a  short,  thick,  pedicle  which  showed  a  funnel 
shaped  opening.  Kitter^  declares  that  in  a  five  weeks  embryo  which  he 
examined,  the  i)edicle  had  no  lumen,  and  the  lens  seemed  to  contain  a 
small  hollow  space.""  VV/f  prsi  pn-hxl  »f  dcvclopnienl  of  the  lens  is  enni- 
plch'd  irilli  III!'  rliisiiir  uf  III  is  irsirli'. 

The  time  when  this  occurs  ha>  been  but  partially  determined.  Accord- 
ing to  KoUilrr^  in  the  chick  the  lens  vesicle  is  cut  off  by  the  third  day. 
and  this  is  in  ai-c-ordance  with  an  illu>tration  by  Kessler  of  a  hatching  egg 
of  three  davs  and  >e\i.^n  hours.     Kollihrr  ([).  (i;U)  observed  in  a  rabbit  a 


lAnatoniie  nienschlicher  Enibryoueni.  I.eipsij:  Bd.  I  n.it  Atlas.  1S80.    Bd.  II. 
1882.  pajre  49.  Bk.  1. 

2  Contribution  a  la  historie  du  devoloppeiiK'iit  de  Toeil  huiuain.    Gjiud.  lSi!>. 

3  Zweiter  Beitrajr  zur  Ilistosencse  des  Aujres.  p.  145. 

4  Eutwit-kehmgsgeschichte  des  Mensolieu  iMul  hoheren  thiere  Leipsig.  1870. 
p.  «32. 


20 

thickening  of  tlie  cnticiilar  ))l;Ho  on  ilie  tenth  day,  and  hy  the  twelfth  day 
the  vesicle  had  already  been  cut  oii".  His  fixes  the  age  of  a  human  embryo 
22  ram.  in  length,  and  in  which  the  optic  vesicle  was  not  even  recognizable 
at  from  twelve  to  fonrteen  d;iys,  the  age  of  one  7-T..")  nnn.  in  length  at  four 
weeks.  He  illustrates  one  4  mm.  in  length  in  which  there  is  a  thickening 
of  the  Epiblast.  even  before  the  primary  optic  vesicle  could  be  discerned. 
Surely  from  the  above  we  could  not  be  far  from  wrong  in  attributing  to  au 
embryo  4  mm.  in  length  an  age  of  about  three  weeks.  This  would,  bring 
(lie  completion  of  the  first  period  ahont  in  the  FOUBTH  WEEK.  Bambeke 
and  Kessler's  observations  quoted  above  agree  with  this,  likewise  with  those 
of  Kolliker.  (P.  637).  But,  as  Becker  states,  it  is  well  to  bear  in  mind  the 
fact  that  the  processes  of  development  may  go  on  more  quickly  in  one  indi- 
vidual than  in  another,  hence  exact  statements  as  to  the  age  of  Human 
Embryoes  can  not  be  determined  according  to  certain  fixed  laws. 

During  this  period  of  development,  the  eye  is  devoid  of  the  so-called 
'•form-giving  coverings,"  especially  the  cornea  and  sclera.^ 

THE  SECOXD  PEKIOD  OF  DEYELOPMEXT  OF  THE  LENS. 
In  its  further  development,  the  cells  at  the  proximal  wall  grow  in  a 
distal  direction,  in  man  is  a  saggital  direction,  pushing  in  between  each 
other,  so  that  on  meridional  section  they  appear  to  be  arranged  in  rows. 
The  cells  in  the  centre  grow  more  rapidly,  hence  are  larger  than  those  at 
the  sides.  Since  the  nuclei  of  all  the  fibre  cells  are  found  in  the  anterior 
fifth,  they  will  form  a  convex  zone  which  is  almost  parallel  to  the  anterior 
wall  of  the  Lens.  Meanwhile,  the  cells  at  the  anterior  wall  arrange  them- 
selves in  a  single  layer,  but  show  no  signs  of  growing  lengthwise.  These 
distal  cells  assume  the  appearance  of  Epithelial  cells. 

Kessler  gives  the  following  description  for  the  chick: — 
"Even  before  the  lens  is  cut  off.  signs  of  growth  begin  to  manifest  them- 
selves, more  especially  in  the  median  (proximal)  portion  of  the  leus  germ,  cor- 
responding to  the  region  of  the  subsequent  capsule.  Simultaneously,  with  a  gen- 
eral increase  in  the  enlargement  of  the  organ,  the  cells  arrange  themselves 
closely  together,  and  each  individual  cell  increases  in  size  and  volume.  They 
.assume  spindle  sliapes,  and  their  sharp  points  force  their  way  in  between  the 
neighl>oring  lamellae.  Meanwhile,  tlie  cells  of  the  inner  lamellae  grow  more 
rapidly  backAvard.  lliose  :it  Iht-  sides  iiutre  anteriorly,  while  those  nearer  the 
axis  of  the  organ  grow  niore  rai)idly  Hian  any  of  the  others.  Every  individual 
cell  readies  tlie  posterior  limit   of  tlie  lens  (the  capsule  of  the  lens),  whereas 


5  See  Rilter,  p.  82,  p.  141 


anteriorly,  to  the  distal  coll  wall,  and  thus  tlu-  hollow  space  disapiifars  up  to  a 
just  appreciable  space, whidi  on  cross  section  <an  be  rccoirnizcd  only  by  its  shar^) 
contour." 

■•This  gradual  transition  of  distal  into  epithelial  cells,  and  of  the 
proximal  into  fibre  cells,  primarily  occurs  posterior  to  the  Equator  of  the 
lens,  but  this  process  gradually  extends  more  anteriorly  until  the  Equator 
is  reached.  This  takes  place  in  various  animals  in  a  two-fold  manner. 
Either  the  cells  of  the  anterior  wall  Ijcconic  nari'Dwcr  and  higiici-.  assuming 
more  the  character  of  cylinder  cells  slanting  somewhat  backward  and  curv- 
ing around  those  more  anteriorly  sitnated,  so  that  the  concavity  of  tlie  curv<.- 
faces  forward,  and  thns  gradually  merging  in  the  direction  of  the  proximal 
fibres,  or  there  are  forced  in  between  the  distal  epithelium  and  the  proximal 
fibre  cells,  also  between  proximal  fibres  and  the  proximal  wall,  a  circle  of 
fibre  like  cells,  of  at  first  increasing  and  finally  decreasing  lengths,  those 
posteriorly  gradually  merging  with  the  proximal  fibres,  in  a  manner  anala- 
gous  to  the  previous  method.  This  latter  method  is  true  of  birds  and  sev- 
eral reptiles,  the  former  of  the  remaining  vertebrates,  and  especially  does  it 
apply  to  man.  THIS  SECOXD  PERIOD  IS  COMPLETED  when  both 
distal  and  proximal  cells  have  arranged  themselves  in  a  single  row. -and  the 
hollow  space  which  had  existed  at  the  beginning  of  this  period  has  1)een 
entirely  obliterated  by  the  growth  of  the  proximal  fibres.''    ■ 

Undoubtedly  this  same  process  which  Kessler  has  described  for  the 
chick  also  occurs  in  man,  and  all  the  illustrations  which  Arnold  has  given 
us  for  the  calf,  and  Kolliker  of  the  rabbit,  are  of  exactly  the  same  character. 
"Owing:  to  pathological  conditions  in  the  human  lens,  which  will  later  on 
demand  our  attention,  a  number  of  observations  which  Kessler  made  on  the  em- 
bryoes  of  the  Lacerta  and  the  sheep,  must  be  here  shortly  mentioned.  Whereas 
at  one  stage  in  the  development  of  the  lens  in  the  chick,  the  nuclei  of  the  prox- 
imal cells  are  arranged  anteriorly  in  a  regular  convex  zone,  in  the  Lacerta  they 
are  irregularly  arranged  along  the  entire  wall  of  the  lens.  The  cells  nearest  to 
the  equator,  those  most  peripherically  situated,  are  the  first  to  become  elon- 
gated, and  in  their  growth  make  a  semi-circular  sweep,  whereas  those  more 
centrally  located  in  part  assume  a  spindle  form;  others  appear  irregularly  dis- 
tended, and  tumescent.  In  a  number  of  sections  of  the  lens  of  the  sheep.  Kess- 
ler did  not  observe,  as  in  other  sections  of  the  lens  of  the  same  stage  of  devel- 
opment, the  lens  tibres  growing  lengthwise  toward  the  distal  surface;  but  he 
found  a  portion  even  of  the  longest  tibres  making  very  sharp  curves  towards  the 
lower  surface,  and  even  here  they  seemed  elong.-ited  and  extending  toward  the 
dorso-proximal  tibres.  Kessler  does  not  state  whether  this  is  to  be  looked  upon 
as  the  first  indication  of  the  formation  of  seams.  This  observation  is  cited  to 
demonstrate  the  fact  that  irregularities  in  the  development  of  the  lens  have  been 
observed  during  the  second  period  of  devolopuient." 


22 

'I'lic  i)i-(i\iiii;il  ti))i-('s  liiivc  h('(>ii  ohsorved  lo  oloiijjnto  in  the  onibrvo  of 
a  Triloii  ^i.')  iiiiii.  in  Iciiulli  jiikI  tlic  liollow  space  eiilirelv  filled  up  in  on? 
4.. J  mm.  in  len^lli.  In  ilie  cliick.  this  stajie  is  completed  on  the  fourth  day. 
(Kessler).  Tiiis  luillow  space  was  found  still  present  in  the  embryo  of  a 
calf  o  cm.  in  len>ith.  but  entirely  filled  out  in  one  1  cm.  lon<i:.  hence  the  time 
]'e(piired  for  this  process  to  1)e  eompleti'd  is  (Mpial  to  that  which  an  embiTo 
requii'cs  to  urow  from  1..")  cm.  to  I  cm.  (.\rnol(l  I'lwetzky).  In  the  ]-abbit 
this  proce>s  heoins  on  the  thii'teenth  day  and  is  com])leted  on  the 
cii^hiccnth  day.  possibly  a  little  sooner.  (Kolliker).  The  tinu'  has  not  been 
exactly  determined  for  man.  hut  imdoulitcdiy  takes  jtlace  dui-inti'  the  xccnnd 
III  on  III  II  f  foetal  life. 

Tiii^:  Till  HI)  ]m:ri()J)  of  development  of  the  lexs 

is  |)i'incipaJly  occu])ied  in  the  multiplication  of  the  cellular  elements,  lens 
c<'lls  as  well  as  lens  fibres.  The  former  increase  by  direct  cell  division,  and 
are  distributed  over  the  entire  distal  wall;  the  latter  by  mean.s  of  the  growtii 
of  the  epithelial  cells,  wliicli  lie  along  the  Equator  and  somewhat  behind  ir, 
into  lens  fibres.  This  successive  transition  of  tin-  e([uatorial  epithelial 
cells  into  the  outer  layers  of  nucleated  lens  fibi-es  can  be  demonstrated  in 
all  Yertebi-ates.  and  tliis  alone  is  suificient  proof  to  demonstrate  the  fact, 
that  these  new  lens  fibres  are  derived  from  the  Fi)ithelial  cells  and  further 
that  in  the  gnming  lens,  the  identity  (»f  epit  heli;il-likc  and  fibre-like  cell> 
is  to  be  maintained. 

At  the  close  of  the  secoiul  period  of  develo|)nient,  the  lens  has  attained 
the  form  from  which  it  takes  its  iiame,  as  the  rcsidt  of  the  growth  of  fibres 
in  an  axial  dii'cctiiui,  these  assume  a  slight  cui'vatui'e  with  the  concavity 
toward  the  edge  of  the  lens,  in  contradistinction  to  those  which,  developing 
later  on,  do  so  meridionaliy.  From  now  on,  owing  to  the  development  of 
new  fibres,  at  the  Aequalor,  these  embn'onal  fibres  are  gradmilly  pushed 
away  from  the  line  of  contact  with  the  antei-ior  epithelium,  and  the  poste- 
rior wall  of  the  capsule.  (Ilenle).  even  at  this  time,  the  shortest:  hence 
the  youngest  fibres  continue  lo  nud\e  a  curve  with  the  coiu-avity  outward. 
I'ut  as  soon  as  they  have  made  their  way  into  the  ca|)illary  space  between 
the  anterior  ends  of  the  distally  growing  embryonal  fii)ics.  and  tli(>  distal 
epitheliuui.  and  posteriorly  between  the  posterior  ends  of  I  he  end)ryonal 
fibres,  and  the  postei'ior  capside.  they  take  on  a  cuivatuiH'  with  tlu>  con- 
cavity towai-d  the  axis  of  the  lens.  The  moi'c  this  condition  progresses, 
the  more  llie  lihres  of  the  second  period  ai'c  pushed  away  IVom  the  capsule 
and  the  I'pilhelium.  and  finally  they  b)rm  the  centre  of  the  <'omplete  organ, 
which  is  concentrically  siirniuude.l  hy  the  libre>  of  llu'  third  permd. 


23 

TIIK  S'rKM'CrrifK  of  TIIK  LKNS  .an  onlv  l)c  iin.l.T-i<M).l.  if  w' 
will  !)c;ii'  ill  iniiid  tlic  riicl.  lliat  all  llic  lilirc-  take  llicir  nri^iii  from  llic 
whorl  localcd  aloiii:-  the  a('(|ualor.  and  llial  ils  ^rowlli  is  not  a  liinilcd  oih'. 
As  far  as  is  known,  in  the  ciiihrvoiial  Icii-  of  no  inaiiiiiial  doc-  a  fnll-iirown 
fibre  encompass  one-half  of  the  (•irciimfcrciicc  of  llu'  Icn-.  In  mo>l  animal-^ 
tliis  is  less  tjian  one-half. 

The  -implcst  strueture  is  found  in  ihc  ;:lol)iilar  lcii>e>  «d'  -omc  fishes, 
ampliihia  and  reptiles,  such  a>  llic  ••>lo(k-ri>li.""  niton,  salamander,  frog 
and  lizard.  In  these  animals  the  hhivs  of  each  lamella  i^o  from  pole  to  pole. 
each  llhrc  encircles  one-iialf  of  the  len>.  each  two  form  a  complete  circle. 
Their  arran.iienicnl  iiresujiposes  that  the  lihre.-  are  hroader  at  the  Aefpiator 
and  hi'come  more  pointed  toward  the  pole,  so  as  to  form  a  point;  or.  speak- 
ing more  eoi'rectly.  come  together  in  a  circle  of  irregular  limits.  'I'his  has 
l)een  proven  hy  II.  ^hilk'i'''  to  he  the  case  in  the  l.aceria.  and  has  been 
-nhstantiatt'd  hy  Ki'>sler.  Lenkart.  Sernotf  and  r.ahiicliin. 

In  a  large  proportion  of  li-he>.  amphibia  and  a  feu  animab  (dcdphin. 
rahbit.  s(piii-rel)  the  lens  hhres  of  one  sheath  regularly  meet  each  other 
anteriorly  and  posteriorly  in  a  short  seam  (a  segment  of  a  circle)  and  the 
direction>  of  these  cut  each  other  at  I'ight  angle-.  If  at  the  anterior  pole, 
this  line  lies  horizontally,  at  the  postei'ior  it  lies  vertically.  At  the  same 
time  it  becomes  imiTOSsible  for  the  fibres  to  entirely  snrround  one-half  of 
the  lens.  For  instance,  if  a  fibre  l)egins  anteriorly  at  the  end  of  the  seam, 
it  will  end  as  it  proceeds  meridionally  backward,  posteriorly  about  the 
middle  of  the  seam,  hence  in  the  axis  of  the  lens  at  the  posterior  pole.  Tu 
doing  this,  the  fibres  describe  a  cnrve  anteriorly  and  mie  posteriorly  in  order 
to  gain  a  point  of  attacbnient  to  the  >eam.  Hence  excry  lihre  describes  a 
double  curve.  The  fibres  of  each  layer,  hown'ver.  po^so.-  about  the  sanu. 
length.  In  several  fisb.es.  such  as  torpt'<lo.  a  sort  of  intermediate  ste])  be- 
tween these  two  types  ha>  been  observed,  all  the  hhres  coming  together  ac 
the  posterior  pole,  whereas  anteriorly  they  come  together  in  a  straight; 
seam.  In  most  niammalia  the  fibres  of  each  sheath  meet  each  other  so  as 
to  form  a  regular  t hice-rayi'd  star  figure,  the  central  point  of  which  lies 
at  the  pole  and  the  rays  of  thi>  >tar.  corropoiiding  to  the  seams,  forming 
with  each  other  angles  of  IV'O  degrees.  The  level-  of  these  rays  do  not  lie 
in  the  same  jilane  anteriorly  and  posteriorly,  but  are  turned  from  each  other 
at  an  angh'  of  (id  degrees,  -o  that  each  ray  of  the  anti'rior  -urface  falls 
within  the  open  angle  of  the  posterior.     I'Acn  in  tlii.-  form  of  arrangement. 


rt  (iesanniielte  mid  liinterhisseiie  Sciuilten  lienuisgeg.  vou  Otta  Becker.  1872. 
Bd.  I.  p.  74. 


24 

in  order  that  the  fibres  may  attach  themselves  to  the  seam  or  ray,  they 
make  two  slight  curves  in  opi)osite  directions.  However,  all  the  fibres  iu 
one  lamella  are  of  equal  lengtli.  We  know  absolutely  nothing  as  to  the 
cause  of  these  various  types.  "Woinow  "'  has  studied  the  manner  of  the 
manner  of  tlie  f(u-iiiation  of  this  seam  for  the  second  type,  and  the  third  type 
can  be  understood  from  Arnold's  illustrations.  Possibly,  the  above-quoted 
observations  of  Kessler  concerning  the  lens  of  the  sheep  belongs  to  this 
category. 

If  after  the  close  of  the  second  period  of  development  new  fibres  are  only 
developed  in  the  Aequatorial  region,  a  stage  comes  on,  in  which  these  fibres 
force  their  way  along  tlio  inner  surface  of  the  capsule  toward  the  axis, 
without,  however,  reaching  those  which  are  making  their  way  in  from  the 
opposite  side.  As  a  consequence,  the  fibres  cf  the  second  period  are  de- 
tached from  the  capsule,  pressed  toward  the  centre  of  the  lens,  and  these 
growing  fibres  come  together  behind  them.  Hence  for  a  time,  on  merid- 
ional section,  one  will  find  a  triangular  space,  filled  Avith  tissue  fluid;  this 
space,  as  a  result  of  the  continued  growth  of  young  fibres,  becomes  filled 
up  by  these,  and  in  very  thin  sections  can  only  be  recognized  as  the  line  at 
which  the  fibres  meet  each  other.'' 

It  is  especially  interesting  to  note  that  Kolliker  was  able  to  show  this 
three-rayed  lens  star  present  in  a  five  months'  human  embryo.  The  pres- 
ence of  the  three-rayed  star,  on  the  anterior  and  posterior  surface  of  the 
lens,  simply  signifies  that  at  least  the  first  layers  of  lens  fibres  which  have 
taken  their  origin  along  the  Aequatorial  region,  have  attained  their  full 
growth,  the  fibres  of  the  one  side  anteriorly  and  posteriorly,  touching  those 
coming  from  the  opposite  direction. 

Hence  the  third  period  of  develo])ment  lasts  from  about  the  middle 
of  the  second  month  up  to  such  a  time,  which  for  man  has  not  yet  been  ex- 
actly determined,  but  which,  however,  at  the  very  latest  falls  within  the 
first  half  of  the  period  of  foetal  life. 

At  this  time  not  all,  but  only  those  which  form  the  first  layers  of  lens 
fibres,  have  attained  their  full  length.  The  fibres  extending  from  aequator 
to  seam,  both  on  the  anterior  and  posterior  surfaces  of  the  lens,  are  arranged 

7  Uber  die  enstehimg  der  bipolaren  anorduug  dor  liuseu-faseru.  Wiener 
Sitzungsbericlite,  18G9.    Bd.  LX^  2  Abtli.,  p.  Lll. 

a  Tliose  ob.servatioiis  have  been  beautifully  Illustrated  by  Arnold.  (Beitrage 
zur  eutwickelnngsgescliichte  des  Auges.  lleidleberg,  1874.  Die  Kittsi;bstance  der 
Eudotludien.  A'ireliow  Arch.  Bd.  LXVI.  ]».  77.1  His  ligures  13  and  14  correspond 
exactly  with  figures  :'.  of  Woinow.  Figure  15  shows  a  similar  proceedure  for  the 
anterior  half.     In  tigures  18  and  lit  ilie  three-rayed  star  is  already  present. 


25 

like  the  tiles  on  a  roof,  so  that  the  broad  ends  of  Iho  tlljres  form  an  uninter- 
rupted mosaic  at  the  inner  surface  of  the  i)osterior  capsule  and  the  anterior 
epithelium. 

Only  those  libres  wlucli  arc  sonic  distance  removed  from  the  surface 
reach  to  the  seam.  These  seams  or  rays  are  therefore  simply  the  optical  ex- 
pression of  imaginary  lines  along  whicli  the  ends  of  the  lens  fibres  touch 
each  otlu'v.  And  on  meridional  sections.  Ilicv  ciin  We  Inllowcd  almost  to 
the  centre  of  the  lens;  never,  however,  along  a  straight  line.  The  nearer 
we  get  to  the  centre,  the  smaller  is  the  encompassed  space.  As  a  necessary 
result  it  follows,  that  though  all  the  fibres  in  a  single  layer  are  of  equal 
length,  in  the  various  layers  from  without  inward,  their  length  regularly 
diminishes.  Each  fibre  is  developed  from  an  cpilliclial  cell  at  the  equa- 
torial region.  As  the  cell  elongates,  the  nucleus,  which  was  originally  near 
the  centre  of  the  cell,  gradually  moves  farther  and  farther  away  from  the 
capsular  end,  until,  finally,  as  the  posterior  end  of  the  fibre  grows  to  excess, 
the  nucleus  again  comes  to  lie  in  the  anterior  third  of  the  fibre.  Hence, 
on  meridional  section  the  nuclei  of  all  the  fibres,  in  their  various  stages  of 
growth,  present  a  very  beautiful  ])icturc.  the  optical  expression  of  all  the 
nuclei  being  a  double  curve,  this  being  another  mode  of  demonstrating  the 
natural  curve  which  the  lens  fibres  describe.  In  the  beginning,  the  con- 
cavity of  the  curve  faces  .anteriorly,  and  finally  the  convexity  is  almost; 
parallel  Avith  the  surface  of  the  lens.  Since  this  curve  is  not  an  absolutely 
regular  one,  Becker  ^  suggested  that  the  name  "Kernbogen''  NUCLEAR 
CURVE,  would  be  better  than  that  adopted  by  H.  ^Meyer.  KERX  ZONE, 
NUCLEAR  ZONE.^ 

Kolliker  was  the  first  to  recognize  this  gradual  transition  of  the  epi- 
thelial cells  into  lens  fibres,  and  Yon  Becker  ^^  gave  to  the  picture  which 
these  cells  and  their  nuclei  present  on  meridional  section  the  name  which 
it  has  since  retained,  "Linsenwirbel" — LenstrliorL 

THE  DEVELOPMENT  OF  THE  CAPSl  LE  OF  THE  LEXS 
has  given  rise  to  endless  discussion,  and  the  importance  of  this  subject  will 
become  more  apparent  when  the  subject  of  capsular  ciatrices  and  capsular 
cataract  comes  under  consideration.     One    group    of    observers.    Reinol; 


sUber  den  Wirbel  und  den  Ivprnbogpii  in  der  Mensohlitlien  Linso.    Arch.  f. 
Ausenheilkunde,  Bd.  XII.  1.  1883. 

9  Beitrag  zu  der  Streitfra^*^  ubor  di.-  Knist.-himR  dor  I.inson  fascrn.    Midler's 
Areh..  1851,  p.  202. 

10  Uutersuchungen  uber  don  Ban  dor  Liiise  bei  <lon  Monsclion  nn  den  Wirbel- 
thieren.     Aob.  fur  Optli.  IX.  187?.. 


26 

Babiirhi,,.  Scnii^lJ.  l/n'hrrl,i,h„  .-iikI  .\nn,l,L  coiitciKl  that  the  capsule  is  oE 
Mesodennic  orioin.  \\w  same  fiom  wliidi  the  vascular  covering  of  the  lens  is 
derived:  the  other  .izroup.  iik.iv  especially  Kcsslrr}^  Kollil-er.  Fr.  KrieheV- 
and  niihiih'l^-^  lock  upon  it  a>  an  excretive  product  of  the  cells  of  the  lens 
vesicle,  heiu-e  of  I'U  "!'( >  I)  !<:  I!  M I  ( '  oii-in.  Srhinitcr}^  as  the  result  of 
his  histoloo-ical  and  more  special  l.v  his  chemical  investigations  of 
fresh  eapsule.v.  capMdai-  cicairico  and  ca|)sidar  cataracts,  joined  the 
adherents  of  the  later  view,  iiamelv.  that  they  are  not  to  be  looked  upon  as 
of  connective  tissue  origin.  Availing  himself  of  Kwald  and  Kuhne's  dis- 
covery, that  the  capsule  of  the  lens,  as  well  as  structureless  niemhranes,  arc 
easily  digested  h\  means  of  trjjsin.  acids  and  alkaline  solutions,  whereas 
connective  tissue  i-euuiins  totally  undigested,  he  hnally  concluded  '"that 
there  is  a  large  pi'eponderance  of  proof  in  favor  of  the  view,  that  hoth  the 
capsule  and  its  pathological  fornuitions  are  derived  from  the  same 
source,  being  products  of  the  PZpithelium  of  the  Capsule." 

Babuchin.is  j„  examining  Sernoff's  preparations,  claims  to  have  seen 
nuclei  in  the  cajjsule  of  the  lens,  in  the  embryo  of  a  chick.  IJerger  i''  states 
that  he  made  similar  observations  in  the  human  embryo.  i>ut  Schirmer, 
basing  his  views  on  his  histo-chetnical  investigations,  logically  questions 
the  accuracy  of  their  ohsei'vatio))s, 

Kessler  claims  to  have  seen  the  capsule  present  at  the  clo.se  of  the 
Second  Period  of  Development,  as  does  also  Arnold.  The  latter,  however, 
at  the  same  time  leaves  the  (juestion  undecided,  as  to  how  the  formative 
cells,  at  the  ])osterior  capsule,  which  at  that  time  have  already  l)ecome 
elongated  into  lens  fibres,  could  jn'oduce  an  exudative  substance  to  form  the 
posterior  capsule.  Kessler  tried  in  vain  to  prove  that  the  capsule  was 
formed  simultaneously  with  the  lens  vesicle.  Becker^'  took  a  position 
between  the  two.  and  states  that  he  l)elieves  the  structure  of  the  capsule  of 
the  lens  to  l)e  a  complex  one.  and  that  it  is  only  important  to'  prove  its 
presence  at  the  beginning  of  the  Third  Period.     "For  withont  this  closed 


11  Znr  Kntwiekelunf?  des  AujiV  der  Wirl.ellliiere.   L«'ii)siff.  1877. 
1-' Zur  Entwickellunji'  des  (Jlaslcoi-pers.    Aicli.  fur  Aiiatomie  and  TMiysioloiiie. 
Ant.  Al)tli..  r.  and  ft  H.'ft..   ISSU. 

13  Ucclierclies  sur  le  developi.cnient  dii  cristallin.  (Jeneve.  ISS.'..  Ueferale 
Hirscld.erji's  Centralhlatt.  ISS.",.  p.  2.-,.-.. 

14  Histolofiisclie  und  II  istociieniisclic  luitersucliun.iien  ulier  Kapselniarlte  und 
Kapsel  Cataract  neltst  lienierl^uiiucn  uliei-  das  pliysioloyisclie  Wachsthuni  und 
die  Structure  der  vodern  Iansenl<apsel  (Jraele  Anli..  Vol.  .\XXV.  Bd.  I.  18SD. 

ir.  Strieker's  Handhudi  der  ( Jew.'l.sleiire.  Leip.sij;.  1S72.  p.  10.  !M\ 
16  Benierknnf;en  uher  ilie  I-inseii  Kapsel.  Hirschberjr's  Centralhhitt  fur  Prakt 
Angenheil,  issj. 

1"  Anatoinie  und  I'atliolotzie.  .'ic..  p.  24. 


27 

clnstic  iiu'iiihranc.  wliicli  lidlds  the  ciilin'  conlciit-  of  llic  l(■ll^  t(i,i:cl  hci-  am! 
wliifli  oH'crs  the  sliulij  rcsi>laiuc  lo  llic  yoiiii--  lcii>  lihivs  wliidi  |mi>Ii  ihcir 
wav  ill  l)('t  w  ecu  tlif  pi'Dxiiiial  (il)r('s  on  the  (Uic  liaml.  and  llic  caioiili'  and  ita 
cpilliclinni  on  the  ollicj-.  one  could  not  conipivlicnd  the  rc.Linlaril y  l)oth  in 
ihc  I'oi-ni  and  arran-zcnicnt  of  llic  lens  lihro  uliicli  \\c  >o  niiicli  adiniro.  * 
ScliiMHci-.  liowcvc!'.  conlcnd.-  llial  llii-  ca|(>ulc  is  dcvclojicd  al  llic  liiiu? 
when  the  e|iitheliiiiii  is  still  |ii'e>ent  alon^-  the  iiostciaor  ca|)-ule.  hence 
dniaii";-  tlie  l-"irst  I'ci'iod  of  1  )e\  elopinenl  and  al  the  -aiiic  liiiie.  when  as  a 
result  of  the  elongation  of  the  pi'oxinial  cell>.  tlicii'  |io\\er  to  foi-ni  capsular 
snhstance  is  not  entirely  lost,  lie  even  attril)iite>  lo  the  yoimu  •■fll>  ii^  tliey 
develop  alon<i-  the  c(|ualor  a  siinilar  power,  thoii.uh  to  a  less  dc^i'ec.  In  a 
series  of  calf  einhryoes  w  liicli  he  cxaiiiiiicd  he  foiiiid  hiit  a  very  slioht  dif- 
rerencc  in  tlii<d<iiess  helwecn  the  anterior  and  postcrioi-  cap.-nle.  and  states 
that  tlic  ditl'crcnco  only  hecoines  apparent  later  on.  when  the  |)osterior 
j-einains  thinner  than  the  anterior,  lie  asseHs  that  the  posterior  lens  fibres 
continue  to  pi-odnce  capsular  snhstance  even  in  e\t  ra-iitei'ine  life.  All  tho 
evidence  at  the  present  day  indicates  the  Ciillnihir  (Eclixlcniiir)  origin 
of  the  lens  ca])sule.  and  that  it  he^ins  to  roi-in  with  tlie  very  first  period  of 
develoj)nient  of  the  lens. 

Tlie  (jKi's/iiin  of  Ihc  ilrrrhi/iijirnl  of  llic  Zoiiiihi  of  Ziiiii  is  even  al  tlio 
pi'eseiit  day.  a  matter  of  douht.  Tiie  \  iew.  however,  is  generally  accepted 
tluit  it  is  derived  from  the  N'itreous  and  of  ^lesoderniie  ori>iin. 

.lulius  Arnold.'"^  reviewin<i-  all  the  literatui-e  on  the  sul)jecl.  shows  u? 
that  ipiite  a  diversity  of  opinions  existed,  and  even  at  the  present  day  they 
liave  not  heeii  entirely  set  aside.  C^/^r  set  of  ohservers.  anion,::- t  luMii  Z//(/;, 
(Dese.  anat  oculi  huinain),  from  whom  this  structure  tal-cer^  its  name:  Mnitrc 
Jean  (Trait  des  maladies  de  Loeil).  SI.  )'ics  (Trait  des  maladies  (le  yeux), 
lloiilioiiniic.  (Cephalotomie).  ( 'dsschnlini.  (.Method  sec),  and  I'clil  (.Mem.  St". 
Acad,  n--^(i)  eontended  that  the  zonula  was  derived  from  the  limiting;-  mem- 
l)rane  of  the  vitreous,  which  al  the  ori'a  sei-rata  split  up  into  two  leaves 
which  attached  themxdves  to  the  aiitcieu'  and  polerior  capsule  of  the  lens. 
A  second  contin>i('nt .  anion^  them  Fcrrciii.  I'dlliici  and  SoIoiikhi .  consid- 
ei'cd  the  zonula  as  a  continual  ion  of  ihe  retina.  A  third,  aiuon.u-  them 
L'inlolplil.  Polllin/ci:  l/cssclhorli  and  Wchcr.  considered  the  /(Uiula  a>  en- 
tirely independent  formation. 

Ileiile  (l-:iiio-ewei(l  lehre  ISdC.)  joined  in  the  views  of  the  lir>t  ,i:roup 
with  this  difrcrence.  ihat  lliouuh  he  looked  upon  the  zonula  a-  derived  from 
lhe  hvaloid.  he  considered  ihe  latter  a  coiitiniiatiou  of  the  limitau>  in- 
terna   retina.      Lieher-kuhn    (Cher  <la>   Au.uv  ^Wv   Wirhelt  hieivn.      Marhur- 


isr.raefe  Saemiscli  Handlmcli.  Vol.  I.  i).  .".n.-.  1S74. 


28 

1872),  liowever.  jn-oved  that  tlie  hyaloid  liad  nothing  to  do  witli  tho  retina, 
and  that  it  is  the  limiting  membrane  of  the  vitreons,  hence  derived  from  the 
mesoderm.  SrJnralhe^^  coincides  with  Lieber-kuhn  as  to  the  origin  of  the 
zonula  from  the  vitreous.  He  does  not  accept  a  splitting  of  the  hyaloid 
at  the  orra  sei-rata.  hut  contends  that  a  thickening  takes  place  at  the  orra 
serrata.  and  that  the  entire  nicruhrane  extends  forward  to  form  the  anterior 
wall  of  Tetit's  Canal,  the  ])osterior  wall  heing  due  to  a  thickening  of  the 
vitreous.  A.  Hannover  -^  otl'ered  a  still  more  complicated  view,  stating  that 
after  the  splitting  into  two  leaves,  the  anterior  again  split  into  two  leaves, 
one  extending  over  the  ciliary  body  and  its  processes  and  then  going  over 
to  the  anterior  surface  of  the  lens,  whereas  the  posterior  of  the  first  two 
together  with  the  posterior  of  the  original  division  should  form  a  second 
canal  posterior  to  Petifs  Canal  known  as  Hannover's  Canal. 

Arnold  gives  us  the  following  explanation:  "At  an  early  period  of 
foetal  development,  the  lens  is  imbedded  in  a  delicate  tissue  derived  from 
the  mesoderm,  which  is  pushed  in  between  the  lens  and  the  secondary 
ocular  vesicle.  This  tissue  gives  off  processes  which,  spreading  around  the 
lens,  gain  its  anterior  surface.  Later  this  tissue  goes  to  form  the  choroid, 
processus  ciliare  and  the  iris.  That  portion  posterior  to  the  lens  forms  the 
vitreous,  the  part  anteriorly  forms  the  membrano-capsulo-pupillaris.  The 
portion  aloug  the  equator  forms  the  zonula.  At  a  certain  time  no  more 
intimate  connection  than  this  exists  between  vitreous  and  retina,  or  be- 
tween zonula  and  the  ciliary  pori;ion.  Later  on,  a  more  intimate  con- 
nection is  established  between  zonula  and  ciliary  body."  He  concludes 
that  the  limiting  membrane  of  the  vitreous,  as  also  the  portion  from 
which  later  on  the  zonula  is  developed,  are  totally  independent  of  the 
retina  in  their  origin  and  that  the  zonula  is  simply  a  "peculiarly  arranged 
and  specialized  part  of  the  vitreous,"  originally  solid  in  its  construction 
and  of  mesodermic  origin.  This,  he  states,  "does  not  preclude  the  possi- 
bility of  softening  or  fluidity  of  the  intercellular  cement  substance  so  as 
to  pennit  the  formation  of  fibrillae,  as  we  see  them  in  the  posterior  part  of 
the  zonula."  Merkel  (Die  Zonula  Ciliaris  Leipsig,  1870)  was  the  first  to 
doubt  the  existence  of  Petit's  Canal,  and  that  the  zonula  was  a  continuous 
membrane.  He  looked  upon  this  space  as  the  result  of  the  elements  of  the 
zonula. 

Czermak  -^  investigati-d  this  subject  very  carefully,  and  his  views  agree 
with  those  expressed  by  Gerlach,  (Beitrag  zur  normalen  anatomie  des  Auges. 


19  Graefe  Saomisch  llandbuch,  Vol.  I,  p.  458. 

20  Entdeckuns  dos  Ban  des  (Ilaskorpers.     Muller's  Arch.,  1845. 

21  Zur  Zonula  Frago-Graef  Arch.,  Vol.  XXXI,  Bd.  I.  p.  74-134.  1885. 


29 

Leipsig,  1880),  who  believed  lliat  the  Zdiiula  consisted  of  a  syslcin  of  mcrid- 
ionally  placed  fibres,  wliicli  take  tlicir  ori.yin  froin  the  ciliarv  Ixxly  and  the 
orbicularis  ciliaris,  and  thai  thcv  ai'c  iiidcpciidciii  of  ihc  vitrc(>ii.-  hody.  and 
he  further  denies  the  existence  of  I'ctits  Canal,  l.aler  investigators, 
Schoen "  and  Top(danski,23  agree  almost  in  lalo  willi  C/.ci-niak.  As  the 
result  of  liis  investigations,  Czermak  states  thai  in  cai'ly  ro<'tal  life  the 
space  between  cihary  body  and  lens  is  filled  up  by  a  large  number  of  foetal 
cells,  which  aiTange  themselves  in  rows,  leaving  spaces  between  them. 
These  cells  elongate,  forming  fine  threads  or  fibrillac  arranged  nieridionally, 
hence  the  zonula  is  not  a  membranous  structure,  hut  a  complicated  system 
of  fibres  from  the  beginning.  In  a  six  and  one-half  montli  foetus  he  found 
the  entire  posterior  eliamber  oceujiied  l)y  the  zonula,  and  a  eondilitm  pres- 
ent never  seen  in  a  fully  develo])ed  eye.  namely,  pencils  of  these  rays  of 
fibrillae  extending  from  the  peripheric  portion  of  the  iris  and  the  most 
anterior  part  of  the  ciliary  body.  Later  on,  as  the  result  of  rarefaction, 
these  fibres  are  restricted  to  the  posterior  portion  of  the  posterior  chamber, 
and  the  pupillary  membrane  disappears  at  the  same  time.  He  looks  upon 
the  zonula  as  of  mesodermic  origin,  derived  from  the  portion  of  the  em- 
bryonal vitreous  which  fills  up  the  space  destined  to  become  the  posterior 
chamber,  and  that  this  tissue  is  "modified  both  physically  and  chemically 
so  as  to  serve  its  function." 

Others  again,  as  Abey  ^^  and  Kuhnt  and  Berger.--^  return  to  the  view 
that  the  zonula  is  a  membrane,  the  fibrillae  Berger  considered  as  fibrillae 
wdiicli  support  the  membrane. 

Finally,  E.  Treacher  Collins,^^  as  the  result  of  the  examination  of  an 
eye,  enucleated  from  an  infant  three  months  old  under  the  supposition  that 
it  contained  a  new  growth,  and  which  was  found  to  contain  a  persistent 
hyaloid  and  exhibited;  fibres  of  the  suspensory  ligament  in  all  stages  of  their 
development,  and  the  subsequent  examination  of  several  foetal  eyes,  formu- 
lated the  following  idea  as  to  the  development  of  the  zonula. 

"For  a  long  time,  the  primitive  lens  remains  in  contact  at  its  sides  with 
the  portion  of  the  secondary  ocular  vesicle  destined  siibsequently  to  become 


22  Zonula  und  Grenzehaut  des  Glaskorpers.  Graefe's  Arch.,  Vol.  XXXII,  R 
2.  1).  149,  1886. 

23  Uber  den  Ban  der  Zonula  un<l  rnitiehunp  iu>bst  bemerkungon  ubor  das 
Albinotische  Aiige.     GraetVs  Arch..  Vol.  XXXVIIl.  B.  1.  1801. 

24  Der  Canalis  Petit  und  der  Zonula  Zinnil  l)eini  Mensch  und  bei  Wirbel- 
thieren.     Graefe  Arch..  Vol.  XXXVIIl.  H.  I.  ISS'J. 

25Beitrag  zur  Anatomie  der  Zomda  Zinnii  Aich.  fur  Opth.  XXVIII.  B.  II, 
1882. 

26  On  the  development  and  abnormalities  of  the  Zonula  of  Zinn.  The  Koyal 
London  Opth.  Hospitiil  Reports.  Vol.  XIII,  Vol.  I,  p.  SI. 


30 

the  eiliarv  body.  Tlie  leii>  lK•(•()lllt■^;  encircled  hv  w  hat  is  terined  its  fibfo- 
vascular  sheath,  derived  in  part  from  the  central  artery  of  the  viireous  and 
in  part  from  the  vessels  growing  in  between  tlic  lens  and  the  cornea.  The 
portion  of  the  inner  layer  of  the  secondary  optic  vesicle  still  in  contact  with 
the  lens — that  is,  the  pars  ciliaris  retinae — acquires  adhesions  to  this  sheath. 
Then,  as  the  eyeball  enlarges,  it  does  so  at  a  greater  late  than  the  lens,  so 
that  a  portion  of  the  ciliary  body  which  was  in  contact  with  the  lens  grow^ 
awav  from  it  and  the  adhesions  which  liave  formed  between  them  become 
stretched,  and  the  cells  forming  them  much  elongated,  imtil  only  fibres  with 
nuclei  lying  on  them  can  be  distinguished,  and  ultimately  the  nuclei  go. 
leaving  only  the  delicate  fibres  of  the  suspensory  ligament  as  we  see  them 
in  the  adult  eye." 

As  a  result  of  the  tension  of  these  elongating  fibres,  the  antero  posterior 
diameter  of  the  originally  almost  globular  lens  takes  on  its  lenticular  form. 
He  also  suggests  that  this  mode  of  development  may  throw  light  on  some  of 
the  congenital  abnormahties. 

Collins,  however,  raises  the  whole  <piestion  again,  when  he  states  that 
he  was  unable  to  definitely  determine  whether  the  cells  which  form  these 
fibres  are  derived  from  the  fibro-vascular  sheath  of  the  lens,  hence  ))tesob]a.<- 
tic,  or  from  the  cells  of  the  inner  layer  of  the  secondary  optic  vesicle  whicli 
form  the  pars  ciliaris  retinae,  hence  Epiblastic.  or  n  ])art  form  one  or  in  ])art 
the  connective  tissue  class,  hence  of  mesoblastic  origin. 


CHAPTER  II. 

THE  GROWTH  OF  TIIK  LEXS. 

In  contradistinction  to  its  i)eriod  of  foetal  development,  the  growth  of 
the  lens  may  be  said  to  begin  at  the  time  when  the  first  lamellae  of  len> 
fibres  which  take  their  origin  at  the  Equator,  conipletely  sui-round  the 
pro.ximal  fibres  which,  as  we  have  seen,  grow  in  an  axial  dirc'ction  and  form 
the  original  nucleus.  Ilir  lens  hody  of  ilie  second  period,  and  press  them 
awav  from  the  distal  epithelium  and  the  posterior  capsule.  Erom  this  tinu\ 
up  to  birth,  this  production  of  fibres,  which  oiu'  after  the  other  elongate  to 
reach  a  seam,  goes  on.  During  this  i»eriod.  the  lens  is  almost  globular,  but 
owing  to  the  Drestuice  of  many  fibres  which  have  not  attaint'd  their  full 
length,  all  of  which  ci-o>>  the  e(|uat(.r.  the  e(|nalofial  diamet.'r  mu.<t  be 
somewhat  greater  than  tlie  axial.  Since  the  human  lens  at  birth  shows  tin- 
same  star  figure  as  does  a  live  months"  foetus.  Ihe  /irsi  period  id'  ijroivlh  r.r- 
fends  from   ohoiil  llir  iiilddlr.  lo  Ihr  rinse  of  foeliil  life. 


31 
77/r'  Srcond  or  E.vl ni iilrriiic  /irrlnd  of  i/rdir/li  \>  ommiI  i;il  ly  a  font iruia- 
tion  of  tlie  first  poiiod,  with  ilii>  (lilVcrciKc.  ii;iiiicl\.  ;i  (lijimctric-ally  oppo- 
site i)nK'es?  beo-ins.  which  we  will  dcsi-iniilc  ;i,-  oiic  of  I' II  Y SI OLOdJCAL 
nETHOanKSSlOS.  Thoc  .liain.'ti-icnllv  op|.o>itr  coiiditions  diviih-  tli. 
e\ti-ii-iitci-iiu'  period  into  two  i^rcal  periods,  one  (d'  extra-uterine  growth,  Ujt 
to  its  complete  development:  the  other,  ihat  of  retrogression  to^^etlier  wit'i 
the  chan^'es  incident  to  a  i-ednction  in  v(diinie. 

How  ureat  the  inci'ease  in  volnnie  is.  may  he  jnd,i:-e<l  hy  the  foilowinp-: 
Tlie  weii^ht  of  a  lens  taken  from  a  foetns  in  which  the  total  ocular  axi.-, 
measured  ]  •")  mm.  was  0.0^  iirammes,  ( I'.ecker).  wlierea>.  at  hirlh.  in  an  eye 
having  an  ocular  axis  of  1^  mm. the  lens  wciuhed  0.10  grammes, ( l)ecker),;ind 
Sappey  I'stimates  the  average  weight  of  an  adtdt  lens  at  O.^IS  grni.  'I'hi- 
increase  in  volume  is  accompanied  hy  a  very  natural  increase  in  the 
e(iuato]'ial  diameter  of  from  ■")  mm.  to  10  mm.,  whereas  the  saggital  diam- 
eter, the  axis  of  the  lens  according  to  Sappey,  remains  almost  unchanged,  -t 
to  4.M  mm.  The  lens  of  the  human  foetus  and  of  tlie  new-born  child  is 
almost  glol)ular.  whereas  in  an  adult  the  surface  has  a  much  sharper  curva- 
ture. 

In  tlie  following'  table  the  absolute  weight  ajjrees  exactly  with  the  state- 
nieuts  of  Sappey.  AVeisht  and  volume  (with  but  one  exception)  increase  steadily 
with  ajre.  The  speoitic  jtiavity  varies  slightly  from  the  average.  The  extremes, 
however,  bear  no  close  relationship  to  the  age. 

Some  slight  doubt  is  cast  on  the  accuracy  of  these  results,  because  the  lenses 
had  been  in  Muller's  fluid  for  various  periods,  some  for  several  years;  and 
further,  because  the  number  of  examinations  is  not  large  enough.  All  the  lenses 
were  obtained  post  mortem. 


Absolute 

Volume. 

Specific 

Weight. 
Gr. 

Cu.  Ctm. 

Gravity. 

\ 

Foetus 

0  070 

•> 

0.10 

3 

20  yrs. 

O.IS 

0.155 

1.1B129 

4 

20     " 

0.185 

0.159 

1.18352 

S 

22     " 

0.215 

0.177 

1.1315S 

6 

40     " 

0.190 

0.163 

1.24248 

7 

49     " 

0.225 

0.194 

1.15979 

8 

49     " 

0.240 

0.198 

1.21212 

9 

54     " 

0.246 

0.214 

1.1448(5 

10 

54     " 

0  245 

0.214 

1.1448ti 

11 

60     " 

0.251 

0.217 

1.15668 

Average  .  .  .  0.219 


0.198 


1.16946 


Priesthey    Smith  i    has    verified    all     Becker's    statements,    at    the     same 


1  Oph.  Society.  1883,  p.  79.  reprinted  in  his  monograph.  '"The  Pathology  and 
Treatment  of  Glaucoma."  1801. 


time  avoiding  his  sources  of  error.  siiK-c  all  the  eyos  which  he  used  were 
removed  one  hour  after  death,  and  at  unoe  immersed  in  viti'eous  fluid, 
in  order  to  prevent  gain  or  loss  in  bulk.  He  states  (Page  84),  "15G  eyes 
were  removed  from  <lead  subjects  in  nearly  equal  numbers,  to  the  six  de<'ades 
of  life  between  20  and  SO  years,  and  a  smaller  number  between  80  and  90.  Each 
lens  was  accurately  weighed,  and  then  measured  as  to  its  volume  by  means  of 
a  spetfial  apparatus  devised  for  the  purpose.  In  most  cases  the  linear  dimen- 
sions wcrt"  measured.  The  specific  gravity  was  calculated  in  each  case  from 
weight  and  volume.  The  crystalline  lens,  so  long  as  it  is  healthy,  increases  in 
weighfand  volume  throughout  the  whole  of  life.  During  the  40  years,  between 
25th  and  65th  year,  it  adds  about  one-tliirdvto  its  weight,  one-third  to  its  vol- 
ume, and  one-tenth  to  its  diameter.  The  specific  gravity  seems  to  vary  little 
in  the  individual  cases,  but  shows  no  decided  changes  with  the  advance  of  life. 
(Page  89.)  In  many  text-books  the  dimensions  of  the  Crystalline  Lens  are  incor- 
rectly stated.  Thus  in  Graefe's  Saemisch  Plandbuch,  Vol.  I,  p.  43-45,  the  antero- 
posterior diameter  of  the  lens  is  given  as  3.7  mm.  This  is  too  small,  even  for 
a  young  adult,  and  for  the  middle  and  advanced  adult  life  it  is  much  too  small 
in  elderly  people.  I  have  found  the  lens  measuring  6  to  even  6.5  mm.  in  di- 
ameter." 

PAGE  174.      AVERAGES. 


A 

B 

c 

D 

A(;e  in  Vks. 

Weight  in  Mgr. 

Volume  in  Cub.  m:m. 

Spec.  Gray. 

Diameter. 

20-29 

174 

163 

1067 

8.67 

30-39 

192 

177 

1085 

S.96 

40-49 

204 

188 

1085 

9.09 

50-59 

221 

205 

1078 

9.44 

(iO-69 

240 

225 

1067 

9.49 

70-79 

( 245 ) 

(227) 

(1079) 

9.64 

SO-89 

( '2m  ] 

(244) 

(1090) 

9.62 

NOTE.--Above  the  age  of  69,  the  number  of  transparent  lenses  examined 
was  much  smaller  than  in  the  earlier  decades.  The  averages  are  given  in 
brackets,  and  must  be  taken  as  less  certain  than  those  belonging  to  the  earlier 
periods. 

Bernliard  Dub.i;  examined  a  series  of  lenses  ranging  from  tlie  ninth 
month  up  to  twelve  years.  All  his  measurements  were  made  with  a  Zeiss 
millimeter  scale  under  the  microscope.  As  will  be  seen  from  the  table,  though 
the  equatorial  diameter  is  not  exactly  proportionate  to  the  age.  it  sliows.  never- 
theless, that  the  lens  increases  in  size  as  age  advances. 


2  Beitrag  zni- 
Vol.  4.  1S91. 


intniss  der  C 


/unnlaris.    Graef  Ar(h..V..l.  XXXVII. 


33 


Age. 

IvENGTH 

OF  Body. 

Equatorial  Diameter,  mm. 

.Sagittal  Diameter,    mm. 

Size. 

Maxim. 

M-I^To^ 

SIZE.    JMAXIM.      MIN.    1  ^^c,E*' 

1 

2 
3 

10  mths. 

11  " 
11 

52 
50 
60 

6.8 
8.0 
7.6 

H.O 

-6:8 

7.46 

2.2 
2.4 

2.8 

'2.H       '±'2 

2.46 

4 
5 

12  " 

Is  *.: 

13  " 

IX  yrs. 

1%    " 
1'/   " 

l}4  " 
V/z    " 

I'A  " 

i>^  " 

iy2  " 
lyz  " 
lyz  " 
i>^  " 
1^  " 
1^  " 

IK  " 

13/     " 

62 
66 
62 
74 
84 
64 
(52 
82 
70 
65 
64 
68 
74 
76 
74 
62 
72 
71 
66 

7.8 
6.9 
7.6 
8.0 
80 
8.1 
8.0 
8.0 
8.1 
8.3 
7.5 
8.0 
8.2 
7.4 
7.8 
7.8 
8.1 
8.1 
7.9 

2.6 
9  5 

.   .   .  1  .   .  . 

6 
7 
8 
9 
10 
11 

'. '. '. 

- 

2.5 
2.6 
2.9 

2.6 

2.8 

.  .  .   j  .  .   . 

•   •   • 

12 

■  ■ :   z  ^ 

13 
14 
15 

16 
17 

18 
19 
20 

8.3 

6.9 

; : : 

7.87 

i.6 
2.2 
2.4 
2.6 
2.6 
2.5 
2.8 
2.6 
2.6 
24 

2.9        2.2 

.   .   .  i   .   .  . 

.   .   .  j   .   .   . 
...... 

2.57 

21 
22 

...... 

...... 

23 

2       " 
2       " 
2       " 

2/    " 

^       76 

82 
78 
68 

8.2 
8.4 
7.9 
8.3 

■8;4' 

7!9' 

.  .  .  i    2.6 

'.   .  .   i    2.5 

8.2    ■    2.8 

.  .  .  ,    3.0 

24 
25 
26 

'3I0        2!5 

"2.72 

27 

28 
29 

3       " 

3>^    " 

70 

86 
80 

8.6 
8.6 
8.2 

'8!6' 

'8!2' 

...       2.8 
8.46       2.9 

...  1    2.8 

.   .   .   1   .   .  . 
2.9    ;    2.8 

'2.83 

30 

4       " 

■5/2      " 

7       " 
12       " 

84 
100 

85 
129 

7.8 
8.4 
8.2 
8.8 

.   .   . 

3.1 
3.2 
2.9 
3.4 

'.'.'.'.'.'. 

31 
32 
33 

.  .   . 

"Finally,  Treacher  Collins  3  examined  a  series  of  foetal  eyes  from  the  fourth 
to  the  ninth  month.  This  table  also  shows  that  the  axial  or  transverse  diameter 
of  the  lens,  which  at  the  fourth  month  is  only  a  llttlo  more  than  the  antero- 
posterior, in  the  adult  is  nearly  three  times  as  nmch.  Also,  that  in  adult  life 
the  antero-posterior  diameter  is  somewhat  less  than  in  foetal  life. 


No.  OF  Eyes 
Examined. 

Diameter  of  Eyeball. 

Diameter  of  Lens. 

Age. 

Antero 
Posterior. 

i  Lateral. 

Vertical. 

Antkro 
Posterior. 

Equatorial 

OR 

Transverse. 

fe     4  mths. 
3     5     " 
^    6     " 
<    7     " 
w    9     " 
^     Adult. 

3 

1 
4 
8 
3 
Merkel. 

8.1    mm. 
11.75     " 
12.50     " 
14.30     " 
16.75     " 
24.3       ♦' 

1    7.8  mm. 

1  11.5  " 
12.0  " 
13.2     " 

j  16.  " 
23.6     " 

7.5  mm. 

10.5  " 
11.1      " 

12.6  " 

15.3  " 

23.4  " 

2.8    mm. 

3.5       " 

3.8       " 

4. 

4.3       " 

3.7       " 

3.3     mm. 

4. 

4.5 

5. 

5.55       " 

9.00       " 

Thus,  if  we  arrange  a  table  from  the  foregoing,  showing  the  growth  of 
the  equatorial  and  axial  diameter  of  the  lens  from  the  early  period  of 


3  Abnormalities  of  the  Zonula  of  Zinn.     The  Royal  London  Opth.  Hospital 
Reports,  Vol.  XIII,  p.  86,  1893. 


foetal  lift'  up  to  the  exti-ciiic  auc  it  at  once  l)eeoines  evident  how  extremely 
rapid  the  growth  of  tlic  lens  is  in  intrauterine  life,  as;  eoni|)ai-('(l  with  th(^ 
extranterine.  Furthei-.  that  in  earliest,  life  the  lens  i.s  almost  filobular,  bni 
as  life  advances  liecomes  Hatter. 


lyCATOKIAI 


Antero 


Diameter. 


4th  month, 

3.3    mm. 

2.K    mm. 

COIJJNS. 

Foetal 

oth       " 
Hth       " 

4.0 
4.5 

3.5        " 

3  8        " 

Life. 

7th       " 

5.0 

4.1 

9th 

5.7 

4.2 

9th  to  12th       " 

7.46      •• 

2  46      " 

1  to    2  years, 

7.87      " 

2.67      " 

2  to    8 

S.2 

2.72      " 

Dub. 

After 

Hto    4       " 

S.4(5      " 

2.83      " 

Birth. 

4  to    6       " 

7.S 

3.1 

5  to    (> 

K.4 

3.2 

7       " 

S.2        " 

2.9 

12       " 

8.8        " 

3.6        " 

20  to  29 

8.67      " 

:Wto39       " 

8.90      " 

PRIESTI.V 

After 

40  to  49       " 
50  to  59 

9.09      " 
9.44      " 

Smith. 

Birth.   * 

(50  to  (59 
70  to  79 

KO  to  S9 

9.49      " 
9.64      " 
9.62      " 

The  following  average  measurements  for  the  lens  in  the  new  born  are  quoted 
in  a  recent  publication  by  E.  V.  Hippel  (Uber  das  Auge  des  Xeugel)(»renen.  Graef 
Arch..  Vol.  XLV,  Part  II.  p.  29.S.  1898): 


Antero 

Equatorial  Diameter. 

Posterior. 

V.  Yager, 

4.5142 

6.3628 

Huschke, 

5.18 

6.76 

Sommering, 

4.28(54 

5.188 

Krause, 

4.512-4.737 

6.768—7.219 

IVIerkel  &  Orr, 

5.0 

9.6.  For  both  Ant.  and  Post.  Surface.-  Radius  of  Curv- 

Dieckman, 

5.1 

(5.29                                                                [ature,  3.3  mm. 

Treacher  Collins, 

4  3 

6.76 

E.  V.  Hippel, 

(  3.76 
14.00 

6.00.     (Two  absolutely  fresh  Eves.) 
6.6 

.\s  we  have  seen  on  page  •*:').  the  tri-star  figure  is  accepted  as  the  type 
at  birth,  with  the  star  on  the  p(i>terioi-  sui-facc  of  the  lens  lui-ned  at  tiO 
degrees  lo  the  (»iie  on  the  anlcnor  .-urfacc.  i'.ut  in  its  furthrr  dcvclopmenc 
after  l)irlli.  a  more  coinpliciilcd  figure  is  foi-med  bv  the  foruialioii  of  sec- 
ondary rays.  Near  the  pole,  each  primai-y  ray  diviih's  into  two  I'ays  forming 
equal  angles  of  60  degrees,  or  each  lay  divi«h'-  into  three  lays.  thus  forming 
equal  angles  of  40  degrees,  or  four  rays,  forming  angles  of  ;!0  degrees.  But. 
as  Beel<er  stales,  (.\nalomic.  p.  ■>]).  "'rhis  does  noi  c.\hau<l  the  variety  of 
ty))es,"  and    he   further  (p.   'iS)  draws  altcnlion    to   the   fad.   ibal    lln'  star 


35 
figure  on  the  anterior  and  posterior  siui'aees  arc  not  of  the  same  type,  henee 
all  the  fibres  in  a  lamella  are  not  of  equal  length,  as  we  found  them  when; 
there  is  the  single  tri-star.  Tie  claims  to  have  seen  the  only  case  (in  a  girl 
twenty  years  of  age)  in  which  ihr  type  on  the  ailterior  and  posterior  surface 
was  the  same.  According  to  Kt)lliker.^  in  these  complicated  star  figures,  it 
becomes  more  dinicnlt  to  understand  the  arrangement  of  the  fibres,  since 
the  fibres,  as  they  attach  themselves  to  the  seam,  are  bowed  in  opposite 
directions,  so  that  their  arrangement  reminds  one  of  a  feather,  at  times 
forming  a  perfect  vortex  {"vortices  lentis").  Thus  it  happens  that  the  per- 
ipheral fibres  of  the  fully  formed  lens  only  lie  for  a  short  distance  in  a 
single  plane. 

Dr.  Percy  Friedenberg.^  as  the  result  of  his  investigations,  (with  Zehen- 
der-Westien  corneal  loup:  also  with  lenses  removed  from  the  eye  and  treated 
with  Xitrate  of  Silver,  1:500  or  1:100),  claims  that  these  schematic  figures 
have  no  basis  in  fact,  that  he  has  found  four,  five,  six  and  seven  pointed 
primary  rays,  and  secondary  rays  could  be  counted  up  to  almost  any  limit 
of  visibility,  making  the  total  of  rays  twenty  or  more.  The  figure  at  the 
pole  is  rarely  that  of  a  true  star,  as  the  angles  between,  the  adjacent  rays  are 
usually  unequal;  besides  this,  the  rays  do  not  issue  from  the  pole  or  from  a 
point  which  corresponds  to  it  approximately,  but  usually  start  from  a 
sutural  line  running  through  the  pole.  In  most  cases  this  line  is  vertical, 
but  not  at  all  infrequently  oblique.  The  number  of  rays  in  the  various 
quadrants  is  not  the  same,  being  greatest  in  the  upper,  next  in  the  lower, 
then  the  temporal  quadrant,  the  nasal  always  being  the  least.  He  found  in 
mammals  that  the  lens  star  corresponds  to  that  of  man. 

The  function  of  the  Eye,  or,  more  properly  speaking,  the  influence 
of  light  on  the  eye,  begins  at  birth.  This  is  not  exactly  true  of  several  iso- 
lated cases  of  mammals,  as  the  rabbit  and  the  marsupia.  At  this  time  the 
anterior  segment  of  the  eye  finds  itself  in  contact  with  a  different  medium. 
As  long  as  the  external  surface  of  the  cornea  is  in  contact  with  the  Amni- 
otic fluid,  there  is  scarcely  an  anterior  chamber.  This  is  only  formed  after 
the  corneal  e])ithelium  is  covered  l)y  a  capillary  film,  whereas  the  endo- 
thelial layer  continues  after,  as  before,  to  border  on  the  increasing  quantity 
of  the  Aqueous.  This  is  in  accordance  with  the  fact,  that  in  animals  which 
live  in  the  water,  especially  in  fishes,  there  is  scarcely  an  anterior  chamber.^ 


4  Handbucli  der  Gewebslehre,  1867,  p.  693. 

5  Then  Lens-star  figure  in  Man  and  the  Vertebrates.    Archives  of  Ophthal- 
mology, April.  1895. 

6  Leukart  R.  Organologie  des  Auges.     Graef  Saemisch,  Bd.  II,  p.  145,  1876, 
p.  250. 


36 

"In  many  of  these  animals  ihe  lens  touclies  the  Cornea,  so  that  tlie  anterior 
chamber  is  jiractically  reduced  to  a  narrow  space  restricted  to  the  periphery. 
In  tliese  cases  the  Cornea  is  very  fiat.  Water,  Cornea  and  Aqueous  have  the 
same  index  of  refraction."  Hence  in  animals  which  live  exclusively  in  the 
water,  we  find  that  the  refraction  of  light  is  mainly  dependent  on  the  lens, 
in  contradistinction  to  animals  wliieh  live  in  the  air.  And  in  accordance 
\nth  this  fact,  the  lens  is  found  to  be  almost  globular.  Here, then, conditions 
purpose,  effect  and  result  mutually  equalize  each  other.  In  the  new-born  in- 
fant ocular  inspection  is  often  sufhcient  to  demonstrate  that  there  is  scarcely 
an  anterior  chamber.  Owing  to  the  gradual  accumulation  of  the  aqueous,  the 
lens  is  not  only  pressed  backward,  but  its  general  contour  is  changed.  This  in- 
creased filling  out  of  the  anterior  chamber  has  likewise  a  lateral  extension, 
especially  toward  the  less  resistant  posterior  chamber.  By  this  means  the 
Zonula  is  drawn  tense,  and  the  lens  is  compressed  in  a  saggital  direction."^ 
From  now  on,  contraction  of  the  Ciliary  Muscle  causes  relaxation  of  the 
Zonula,  and  as  a  result  the  lens  returns  to  its  more  globular  form,  as  it  ex- 
isted during  foetal  life. 

At  birth  the  lens  assumes  various  changes  in  its  shape,  dependent  on 
accommodative  effort.  These  changes  can  not  be  entirely  set  aside,  even  in 
foetal  life,  since  aside  from  the  changes  in  the  "Electrical  Conditions''  of  the 
Oculo-Motorius,  which  must  be  followed  by  contraction  of  the  Ciliary 
Muscle,  the  converging  movements  of  the  eyes  are  associated  with  accom- 
modative eft'orts,  even  in  utero.  Though,  as  far  as  we  know,  accommo- 
dative efforts  do  not  take  place  during  the  first  few  days  or  even  weeks  ot 
extra-uterine  life,  nevertheless  the  action  of  light  on  the  retina  must  lead 
to  a  contraction  of  the  ciliary  muscle. 

As  regards  the  length  of  lens  fibres,  there  appears  to  be  a  very  material 
difference  between  this  and  the  foregoing  period  of  growth.  In  all  that 
has  previously  been  said;  in  the  foetal  lens,  all  the  individual -fibres  of  each 
concentric  lamella  were  of  equal  length.  In  each  succeeding  lamella  the 
individual  fibres  must  be  longer  than  in  the  preceding,  if  the  rays  of  the 
lens  star  increase  in  length  and  each  fibre  occupies  relatively  the  same 
position,  as  its  corresponding  fibre  in  the  layer  beneath.  This  gradual  in- 
crease in  length  extends  to  the  close  of  the  first  period  of  growth,  as  long 
as  the  simple  tri-star  figure  continues.  Kobinsky  *  has  beautifully  described 
tliis  condition.  He  estimates  that  a  fibre  which  starts  exactly  at  the  pole 
anteriorly,  attaches  itself  posteriorly  exactly  at  a  point  where  the  anterior 


7  For  a  different  explanation  sc*'  Collin's  Tlifory,  \k  '■',(). 

8  Untersuchuujjcn  zur  K«>ntniss  dor  Laajio  \uu\  Anonlnung  der  Augen  liusen- 
fasren.     Central),  f.  d.  nied.  Wiss,  1882,  No.  27. 


3  7 
;uul  iiiiddlf  third  nf  tlu'  cunc-iMHidiiii;-  radius  iiirct.  'I'lie  siicfceding  fibres 
(111  llic  aidcrioi-  siiil'acc  arc  all  successively  i-eiiioved  one  fibre's  breadth  from. 
the  |)ok'.  and  on  the  iiosicrioi-  surface  aloii^"  tlio  corresponding  radius,  all 
(he  lil)res  reach  t)iie  libi'e's  hreadlh  successively  nearer  to  tlic  pole,  so  that 
finally  the  lihi-c  whicli  linds  its  point  of  attaclinicnt  on  the  anterior  surface 
at  the  junction  of  tlie  anterior  and  middle  third  extends  posteriorly  to  the 
pole."  .\cc(.r(lin,<:'  t<t  Ifdhinski.  a  lihi'c  taken  from  the  mosi  external 
lamella  of  the  len>  n\'  a  new-horn  infant  measures  o..')  min.  Meas- 
uremenis  of  tlio  lens  fibi'cs  of  adults,  as  compared  will)  the  increase  in  the 
size  of  the  ('(jiiatorial  diameter  of  the  lens,  did  not  show  a  relative  increa,<5e 
in  sizcand. aside  from  this.  I  hey  varied  greatly  (2.74^"  to  4.0(r")  7.17  to  lO.fii 
nim.  ITence  the  fibres  are  neither  of  equal  length,  nor  can  they  reach  from 
one  pole  to  the  junction  of  the  outer  and  middle  third  of  the  corresponding 
radius  of  the  opposite  side.  Direct  observation  has  shown  that  they  end  in 
the  outer  third  of  the  corresponding  radius.  The  length  of  the  fibres  vary- 
in  each  lamella,  and  this  variation  is  all  the  greater,  the  more  complicated 
the  star  figure. 

If  one  will  make  a  sketch  of  both  the  anterior  and  posterior  surface 
of  the  adult  lens,  showing  the  lens  star,  one  will  see  that  if  the  number  or 
rays  is  the  same  on  both  surfaces,  all  the  fibres  will  be  of  equal  length,  jusi 
as  in  foetal  life.  But  if  this  complicated  type  is  difl'erent  on  the  two  sides, 
as  a  necessity  the  fibres  must  vary  greatly  in  length.  Since,  with  the  single 
exception  mentioned  above,  this  latter  type  is  the  one  always  met  with,  the 
fibres  of  a  single  lamella  in  a  human  lens,  and  which  develop  in  extrauterine 
life,  will  not  only  be  shorter,  as  compared  to  the  portion  of  the  lens  which 
they  encompass,  but  they  will  no  longer  possess  an  equal  length  as  com- 
pared with  each  other,  as  they  did  in  foetal  life.  This  inequality  in  the 
length  of  the  lens  fibres  is  to  be  looked  upon  as  the  cause  of  the  great  in- 
crease in  the  radii  which  go  to  make  up  the  star  figure  and  the  production 
of  the  variety  of  types  seen  on  both  surfaces. 

In  lieu  of  a  more  plausible  explanation  of  this  unequal  gi-owth  of  th'^ 
lens  fibres  in  extra-uterine  life,  one  might  be  permitted  to  seek  it,  in  the 
functional  activity  of  the  lens,  and  in  its  uninterrupted  formation. 

The  position  of  the  nuclei  of  these  fibres  is  dependent  on  the  above 
described  in-egularities  in  the  length  and  the  laying  down  of  the  new-former! 
lens  fibres.  In  embryonal  lenses,  even  in  the  new^-born,  the  Nuclear  Zone 
of  nuclei  form  a  convex  curve  on  section.  This  is  not  the  case  in  older 
lenses.     Von  Becker  ^  drew  attention  to  the  fact,  that  at  first  the  fibres 

9  ITntersnf'hunjren  ubpr  den  Ban  der  Linse  bei  den  Mensehen  and  den  Wir- 
belthiertni.    Arch.  f.  Opth.,  Bd.  IX,  1873.  p.  10. 


3S 

grow  only  at  their  anterior  extremity,  as  one  is  justified  in  concluding  from 
the  position  of  the  nuclei,  soon,  however,  the  posterior  extremity  also  grows. 
Thus  it  happens  that  in  the  hoginning  the  nuclei  form  a  limited,  and  later 
on,  a  somewhat  hroader  curve,  which  is  open  anteriorly  and  which  then 
merges  into  the  larger  anteriorly  convex  curve.  According  to  Von  Becker, 
from  now  on,  the  growth  of  both  ends  of  the  fibre  is  almost  equal.  Since 
the  proportion  of  each  fibre  which  is  on  the  anterior  and  posterior  surface 
is  dependent  on  the  arrangement  of  the  radii,  or,  more  properly  speaking, 
on  the  part  which  each  separate  fibre  plays  in  the  formation  of  these  radii, 
therefore  their  nuclei  must  also  occupy  a  variety  of  positions,  depending 
on  the  above  circumstances.  Though  the  general  law,  that  the  nuclei  are 
always  found  in  the  posterior  portion  of  the  anterior  half  of  the  fibres,  is 
almost  universally  accepted,  on  section  the  curve  formed  by  all  the  nuclei 
which  form  the  IMeyer's  nuclear  zone  will  always  be  found  in  the  outer  por- 
tion and  with  the  concavity  of  the  curve  turned  toward  the  anterior  surface 
of  the  lens.  Whether  this  curve  will  in  certain  portions  of  the  lens  extend 
anteriorly,  or  more  toward  the  centre,  or  even  backward,  vn]\  depend  on  the 
variety  and  even  the  condition  of  the  rays  of  the  lens  star.  Von  Becker 
very  properly  concludes,  that  one  should  not  picture  to  one's  self  this 
nuclear  zone  as  though  it  passed  through  the  e(|uatorial  plane  of  the  lens, 
as  though  it  were  a  diaphragm,  but  rather  as  though  it  were  a  sheet  attached 
at  the  periphery  and  which  extended  through  the  substance  of  the  lens,  iu 
a  wavy  manner  and  equidistant  from  the  radii  of  the  lens  star.  If  we  can 
thus  explain  certain  departures  in  the  position  of  the  nuclei,  as  we  find  them 
in  very  thin  sections,  aside  from  these,  we  do  meet  with  well-preserved  nuclei 
in  the  deeper  layers,  dispersed  in  the  most  irregular  manner.  This  rule, 
therefore,  has  its  exceptions. 

In  very  thin  sections  of  the  lens  one  may  observe  still  other  abnormal- 
ities. Henle  (Zur  Anatomic  der  Krystallinse  Gottingen.  1878)- has  pointed 
out  one  which  is  of  great  importance,  namely,  that  the  lamellae  do  not  in- 
crease regularly  in  thickness,  as  we  go  from  without  inward.  Such  a  con- 
dition indicates  that  the  growth  of  the  lens  is  not  a  perfectly  regular  and 
continuous  one,  but  that  it  is  influenced  by  the  same  fluctuations  in  tho 
general  nutrition  of  the  body,  as  are  other  organs,  as  per  example,  the  skin, 
the  hair,  more  especially  the  nails,  on  which,  subsequent  to  a  long-continued 
fever,  one  can  observe  a  line  of  ^demarcation.  There  can  hardly  exist  a 
doubt  but  that  during  the  time  in  which  a  child  is  well  nourished,  the  lens 
fibres  grow  rapidly,  become  broader  and  more  succulent;  whereas,  in 
anaemic  children,  the  growth  is  interfered  with  or  possibly  totally  arrested. 
Such  an  irregular  interference  with  the  growth  of  the  lens  fibres  will  mani- 


39 

fest  il.-<oli'  by  tlie  invi:iil;ii-  inaiiiin-  in  which  ihc  nuclei  nf  ihc  yoiuifrest 
fibres  follow  one  another.  At  times  tliey  follow  each  olliei-  in  a  regular 
curve,  then  again  their  curve  is  inten-upted  by  oiu-  of  more  nuclei  lying  far 
removed  from  it. 

A  host  of  the  older  ohservers  have  stated,  that   in  the  lens  star  is  to 
be   I'onnd  a  partially  honu.genons.  jiartly  tinely  granular  substance  which 
separates  the  fibres  as  they  come  to  meet  each  other  from  opposite  sides. 
Bowman  (Lectures  on  the  Eye,  London,  1849)  described  in  lenses  depend- 
ing on  their  construction,  one,  two,  three  or  more  tri-stars  with  their  points 
directed  toward  the  centre.     He  considered  these  non-fibrous  planes  "cen- 
tral planes."    Kolilker  (p.  711)  found  but  little  of  this  substance  where  the 
lenses  had  been  hardened  in  chromic  acid  and  the  fibres  were  well-])reserved. 
Babuchin  and  Senioff  assert  that  the  fibres  are  in  direct  contact  ([».  1086, 
Babuchiii.    Die  Linse).  A^on  Becker  set  up  the  hyi)othesis  that  tlu-se  central 
planes  were  in  direct  connection  with  a  system  of  inter-fibrillar  space.?, 
which  he  supposed  had  some  bearing  on  the  accommodative  act.     Otto 
Becker  agrees  with  Babuchin  and  Sernoff,  but  denies  the  existence  of  these 
"central  planes"  and  inter-fibrillary  spaces.     These  spaces  are  lenticular 
in  shape  and  filled  with  a  finely  granular  substance.    Their  exact  nature  is 
not  quite  clear,  but  Otto  Becker  suggests  that  they  "are  due  to  irregularities 
in  the  exact  coaption  of  the  one  lamella  over  the  other."  Hence  these  spaces 
are  partly  congenital  and  are  to  be  looked  upon  as  having  been  present 
during  life.     It  is  possible  that  these  interspaces  stand  in  some  causative 
relation  to  some  forms  of  congenital  punctate  Cataracts  or  to  acquired  Cat- 
aracts which  first  manifest  themselves  as  punctate. 

THE  MANNEE  IX  WHICH  THE  LEXS  FIBRES  ADHERE 
TO  THE  EPITHELIUM  AND  TO  THE  POSTERIOR  CAP- 
SULE. Just  a.s  we  found  that  there  is  nothing  other  than  the  so- 
called  ordinary  tissue  fluid  of  the  body  occupying  the  spaces  between  the 
ends  of  the  fibres  as  they  come  together  to  form  the  lens  star,  so,  likewise, 
this  same  fluid  exists  between  the  fibres  laterally  and  between  the  successive 
layers;  likewise  it  is  found  between  the  anterior  capsule  and  the  epithliura 
and  between  the  fibres  and  the  inner  surface  of  the  posterior  capsule. 
Nevertheless,  at  all  the  above-mentioned  situations  we  find  a  domonstratable 
amount  of  organic  material,  which  during  life  is  fluid  or  soft  and  which 
after  death  in  the  hardened  state  may,  or  may  hot  be  demonstratable  by  the 
use  of  various  methods  of  staining.  This  substance  is  the  source  of  those 
prettily  arranged  shallow  depressions  seen  on  the  inner  surface  of  the 
posterior  capsule  of  the  lens,  which  have  been  so  freciuently  the  subject  of 
discussion.    Henle  looked  upon  them  as  due  to  coagulated  albumen.    (Anat- 


40 

oniie.  \).  ()80).  hi  his  Patliolooie  and  'riierai)ie.  paj?e  Ki.").  Becker  expresses 
himself  that  "tlicse  ledges  are  In-aline  deposits  due  to  the  coagulation  of 
albuminous  tliiid  which  becomes  changed  into  these  ^lorgagni's  globules. 
Seen  on  the  flat,  ihey  look  vcrv  much  like  the  cells  of  a  honeycomb,  but 
they  are  not  regularly  six-sided,  and  show  differences  in  size.  This  coagu- 
lation nuiy  occur  during  life  as  well  as  after  death."  liut  at  that  time  he 
had  the  erroneous  idea  that  the  ends  of  the  fibres  could  not  cause  similar 
pictures.  (P.  Hiii).  Dcutschman  ^'*  cx|u-csscd  himself  that  tlu-re  is  con- 
stantly a  sub-capsular  layer  of  albuminous  fluid  present  between  capsule 
and  lens  substance.  Finally.  Ilenle  so  modified  his  original  statement  as  to 
admit  a  connection  Ijctwccn  the  protruding  ledges  and  the  narrow  splits 
which  are  bounded  by  the  blunt  edges  of  the  fibres.  H^  says,  "'They  divide 
the  inner  surface  of  the  posterior  capsule  into  veritable  fields,  the  dimen- 
sions of  which  ec|ual  the  diameters  of  the  fibres."  Kolliker  gives  the  same 
explanation  in  his  microscopical  Anatomy,  Vol.  11.,  page  707.  It  is  more 
than  likely  that  these  ledges  become  permanent  after  death,  the  albuminous 
tissue  fluid  coagulating  as  a  result  of  the  cooling  ofl:'  of  the  body,  or  they  are 
possibly  artificially  produced  when  the  eye  is  placed  in  the  hardening  fluid. 
This  appears  to  l)e  all  the  more  prol)able  since  these  structures  are  found 
more  frequently  and  to  a  greater  extent  at  the  posterior  capsules  of  young 
animals  in  which  the  posterior  capsule  is  still  in  direct  contact  with  the 
ends  of  the  fibres. 

Although  Becker  acknowledges  the  correctness  of  this  view  for  a  cer- 
tain proportion  of  cases,  he  does  not  consider  the  matter  as  definitely  settled. 
He  says,  'T  am  still  of  the  o])inion  that  the  coagulation  of  the  so-called 
Morgagni's  globules  is  the  cause  of  the  impressions  and  the  formation  of 
these  ledges.  These  depressions  are  always  nearly  circular,  and  at  times 
some  of  them  are  still  found  occupied  by  these  Morgagni's  globules.  These 
globules  vary  greatly  in  size.  In  some  specimens  they  are  very  large,  and 
one  can  observe  how  they  are  just  beginning  to  loosen  up.  Finally.  I 
haAc  never  observed  both  formations  in  the  same  preparation.  To  a  degree 
they  seem  to  exclude  each  other,  the  former  being  observed  more  especially 
in  the  fresh  eyes  of  the  young,  the  latter  being  exclusively  found  in 
cadaveric  eyes.  This  is  explained  by  the  fact,  that  in  eyes  in  which  this 
Morgagni's  fluid  accumulates  between  lens  and  capsule,  the  lens  fibres  are 
no  longer  in  contact  with  the  inner  surface  of  the  ca])sule,  and  hence  can 
no  longer  give  rise  to  these  depressions.  In  the  cadaver  the  albuminous 
fluid  which  accumulates  between  the  epithelium  and  the  lens,  the  occur- 


lOZur  regeneration  des  Humour  .\queoiis.     Arch.  Opth..  Bd.  XXVI,  p.  121 
and  p.  99. 


4' 
rence  of  which  lias  given  rise  to  the  ii\\>v  tt'acliiii;^-  ihat  thi-  is  to  be  looked 
upon  as  Iluniour  Morgagni.  also  leaves  behind  it,  when  it  coagulates,  de- 
pressions of  an  analogous  character  on  the  inner  surface  of  the  E]ntheliuni. 
These  figures  are  often  mistaken  lor  AVcdIV  Vesicular  Cells." 

THE  FOR:\rATI()N  01-'  X  KW  LKNS  FIliRES.  As  has  already  been 
indicated,  on  |)age  'i'L  the  laiuelhie  of  the  lens  are  devi'loped  hy  t!ie  forma- 
tion of  new  lens  fibres  along  the  equator.  As  these  new  fibres  develop,  they 
gradually  press  those  already  formed  away  from  the  surface. 

As  long  ago  as  18.51,  Herman  Meyer,ii  in  order  to  uphold  this  view, 
drew  attention  to  the  changes  which  the  nuclei  of  the  fibres  undergo  as  they 
gradually  become  removed  from  the  surface,  and  he  considered  this  as 
an  indication  of  the  gradual  death  of  the  nuclei.  An  incidental  utterance, 
of  II.  Mulleri-  ^lakes  it  probable  that  he  also  Ijelieved  that  the  new  fibres 
are  found  at  the  whorl.  Kolliker  (p.  731)  believed  that  cellular  divisioii 
took  place  along  the  Equator,  thus  constantly  replacing  the  cells  which  had 
been  changed  into  fibres,  and  Von  Becker  claimed  that  he  observed  this 
cellular  division  going  on  along  the  same  line.  Frey  ^^  even  mention- 
nuclear  division  in  the  lens  fibres  of  an  eight  months'  human  foetus. 
Whereas,  Sernoff,  Iwanott*  and  Arnold  did  not  observe  these  karyokinetic 
figures,  Henle  attempted  to  explain  the  assertions  of  Kolliker  and  Von 
Becker,  who  claim  to  have  seen  conglomerations  of  small  cells  along  the 
epithelial  border,  by  demonstrating  that  this  appearance  of  a  number  of 
layers  of  small  cells  was  due  simply  to  the  close  packing  of  the  cells  which 
had  become  elongated  into  fibres,  and  the  swellings  at  the  points  where  the 
nuclei  lay,  were  located  at  various  heights  so  that  the  fibres  could  accommo- 
date their  positions  to  each  other.  To  this  general  description,  Becker  adds, 
"that  in  the  calf  embryo,  as  in  young  pigs,  he  found  a  broad  zone,  in  which 
the  nuclei  wer^  smaller,  closer  together,  almost  touching  each  other,  and 
taking  the  analine  and  haemotoxylin  stains  with  avidity.  The  nuclei 
which  in  the  center  of  the  anterior  capsule  of  the  ox  are  perfectly  round 
and  have  a  diameter  of  0.0047'  mm.,  whereas  the  cells  theniselves  have  an 
average  diameter  of  0.00(57  mm.,  at  the  Equator  have  a  diameter  of  0.0025 
mm.,  with  a  diameter  of  cell  equal  to  0.0029  mm.  At  the  same  time  the 
nuceli  increase  in  height  from  0.004T  to  0.009  mm.,  and  the  cells  elongate 
from  0.00G7  to  0.0174  mm.  One  can  easily  understand  that  such  a  change 
in  shape  will  be  very  apparent  where  the  long  axis  of  the  nucleus  is  exactlj 


11  Beitrag  zur  der  Streit  frage  uber  die  Entstehung  der  Linsen-fasern.   Mul- 
ler's  Arch..  1851.  p.  202. 

12  Gesamelte  und  Hiuter  lassene  Schriften  lierausgegebeu  von  Otto  Becker, 
1872.  Bd.  I. 

13  Handbuch  der  Histologie  uud  Histochemi,  2  Auf.,  p.  287. 


4.2 

perpendicular  to  tlie  surface  of  the  capsule.  From  all  that  has  been  said,  it 
seems  to  be  higlil}-  probable,  that  these  peculiar  pictures  stand  in  close  re- 
lation to  the  nuclear  and  cellular  increase,  and  that  the  large  cells  are  to 
be  looked  upon  as  "mother  cells."  Becker  also  coincides  with  Heule's 
views,  namely,  that  tliere  are  no  so-called  Formative  Cells  (Von  Becker) 
along  the  Equatorial  Zone. 

When  Henle  (Zur  Anatomie  der  Krystallinse,  1878)  published  his 
Monograph,  he  left  the  question  as  to  how  the  new  fibres  are  formed  on  the 
surface  of  the  capsule,  an  open  one,  but  since  that  time,  he  has  published 
some  successful  studies  which  have  elucidated  this  subject.  In  a  thesis 
styled  "Zur  Entwickelungsgeschichte  der  Krystallinse  und  zur  Theilung 
des  Zellkerns."  he  recites  his  observations  on  the  larvae  of  Frogs  and 
Tritons,  in  which  lie  found  cells  interspersed  between  those  at  rest,  and 
often  at  a  considerable  distance  from  the  place  at  which  the  cells  become 
elongated  into  fibres  undergoing  karyokinetic  changes.  He  states:  "In 
the  lenses  of  these  animals,  as  in  all  other  globular  lenses,  the  epithelium 
extends  beyond  the  Equator  on  to  the  posterior  surface.  Along  the  Equa- 
tor the  cells  still  have  their  polygonal  shape,  as  on  the  anterior  surface; 
then  folloAv  a  number  of  rows  of  elliptical,  almost  quadrilateral,  cells:  next 
to  these,  as  long  as  the  lens  continues  to  grow,  rows  of  longer  cells,  which 
run  parallel  to  the  fibres,  and  so  arranged  as  to  lap  over  each  other,  like  the 
tiles  on  a  roof.  In  the  pol3-gonal  cells,  which  lie  near  the  region  of  the 
equator,  one  observes  these  karyoldnetic  changes  going  on.  At  times  these 
changes  are  noted  siugh^,  then  in  numbers;  but  I  could  not  find  that  their 
number  stood  in  any  relation  to  the  age  of  the  larvae.  Xcither  are  the 
cells  nearest  the  Equator  always  the  ones  in  which  the  changes  are  farthest 
advanced.  One  finds  cells  undergoing  division  dispersed  everywhere,  and 
it  is  absolutely  impossible  to  state,  what  it  is  in  the  individual  case,  which 
gives  the  initiative  to  these  changes."  Henle  finally  states  tliat  he  never 
observed  these  changes  in  a  fully  developed  frog  (without  a  tail  and  with 
feet).  It  was  not  until  after  "indirect  nuclear  division"  had  been  fully 
proven  by  Strassburger  for  the  plant  cell,  by  Fleming  for  the  aninutl  cell, 
by  Arnold  for  pathological  cells,  that  the  subject  of  how  the  cells  of  the 
lens  capsule  increase,  both  in  the  normal  and  pathological  conditions,  could 
be  definitely  settled.  It  was  then  shown  that  these  nuclear  changes  are 
pretty  evenly  distributed  over  the  entire  surface  of  the  capsule.  Thev  are, 
however,  only  demonstrable  when  the  specimen  is  hardened  in  Fleming's 
Solution. 

There  wei'c  two  ])ossibilities  as  to  where  these  karyokinetic  changes 
take  place;  either,  as  Muller  thought,  they  occur  near  the  Equator  along 
14   Arch,  fur  Mikr.  Anat,  Bd.  XX,  p.  418. 


43 
the  Ions  whorl,  or  tlie  iucroase  takes  place  all  unci-  llie  anterior  capsule,  thus 
gradually  forcinfr  all  the  epithelial  cells  towai'd  the  Ecjuator.  Ilenle  and 
Becker  believed  in  this  latter  mode  of  increase.  Tleide  says:  "Just  as  ac- 
cording to  Ehert,  the  posterior  epithelium  (?)  of  the  cornea  grows  over  the 
surface,  not  as  the  result  of  the  addition  of  cells  al  llie  edges,  but  by  the 
interposition  of  new  cells  over  ihe  entire  surface,  as  the  result  of  karyoki- 
nesis,  the  cells  push  themselves  in  ht'twcen  the  oM  ones." 

The  observations  of  Eberth  and  Leber  are  of  especial  interest,  owing 
to  the  great  importance  which  this  subject  of  the  movements  of  the  epi- 
thelial cells  across  the  surface  of  the  capsule  bears  to  a  proper  explanation 
and  understanding  of  the  pathological  processes.  (Capsular  Cataract,  etc.) 
Eberth  ^^  has  shown  that  where  there  is  regeneration  of  the  corneal  epithe- 
lium,this  prolifei-ation  is  not  confined  to  the  edge  of  the  defect,but  occurs  at 
a  considerable  distance  from  this  s])ol.  and  in  cells  interspersed  between 
those  at  rest.  Leber ^^  has  shown  that  during  the  healing  of  capsular 
wounds  the  karyokinetic  figures  develo])  in  a  zone  which  is  at  a  consider- 
able distance  from  the  defect.  Between  small  cells,  with  small  nuclei, 
others  are  found  which  are  considerably  larger  and  clearer,  showing  all  the 
vai'ious  stages  of  karyokinesis.  In  the  embryoes  of  calves  and  children, 
Becker  found  these  karyokinetic  tignres  all  over  tlio  capsule,  without  a 
special  activity  being  noticeable  in  any  jiarticular  zone.  Such  an  increase 
of  cells  presumes  that  these  new  cells  force  their  way  in  between  thoso 
already  formed;  the  latter  are  compelled  to  change  their  position,  and  in 
a  centrifugal  direction,  that  is,  from  the  pole  towards  the  Equator.  Thus 
it  has  been  shown  by  direct  observation  that  the  cells  multiply  over  the 
growing  capsule,  and  that  they  change  their  position  over  the  surface  of 
the  capsule,  and  it  is  also  very  probable  that  the  entire  epithelium  in  turn 
replaces  those  cells  which  are  changed  into  lens  fibres. 

THE  CAPSULE  OF  THE  LENS.— It  is  generally  conceded  that  the 
capsule  of  the  lens  grows  during  extra-uterine  life.  According  to  Eitter,^^ 
in  the  new  born,  the  capsule  of  the  lens  at  the  anterior  pole  measures  O.Olti 
mm.  in  the  thickness,  whereas  in  the  adult  it  ineasures  0.0 Ki  mm.,  at 
the  equator,  0.005  to  O.OOT  mm.,  and  at  the  ])osterior  pole.  0.0075 
to  0.008.  As  has  already  been  indicated  on  ])age  '.^(i.  to  Schinnci-  (ref- 
erence on  page  26),  who  proved  that  the  I'apsulc  of  the  lens  is  an  excre- 
tory product  of  the  epithelium  of  the  lens,  are  we  indebted  for  the  most 


isuber  Kern  und  Zelltliciluug.    Vircliow-s  Atfh..  LXVII.  p.  523-525. 

16  Zur  pathologic  der  liiise  Zehcnders  Klin  Monats  blatt.  beilajj  hoft.  p.  33. 
1878. 

17  Anat.  du  cristallin— Wecker  Traite  des  Maladies  des  ycux.  2il  VA.  II.  p.  3. 


44 

modern  and  generally  aec'e])ted  views  regarding  this  structure.  In  the 
course  of  his  investigations  on  Capsular  Cicatrices,  Schirmer  observed  that 
1lie  new  formed  vitreous  lamella  behind  the  cicatrix  increased  in  thickness 
\\  itli  tlie  age  of  the  capsule,  and  to  a  degree  equal  to  that  of  the  surround- 
ing true  (•a]»su]('.  At  the  same  time  the  everted  edges  of  the  ruptured  cap- 
sule appi'ared  continuously  to  decrease  in  thickness.  This,  he  concluded, 
must  be  a  physiological  process. 

In  order  to  gain  more  accurate  data  as  to  the  rapidity  of  both  this  increase 
in  tliiclaiess.  and  tlie  diminution  in  thiclvn«>ss  of  the  outer  lamellae,  he  measured 
all  tlie  cicatrices  produced  in  his  experiments  on  animals,  also  the  new  lamellae. 
He  estimates  .Tnlia  Sinclair's  (Experimentelle  T'ntersnchunjren  zur  Genese  der 
erworbenen  Kapsel  cataract.  Inaug.  Diss  Zurich.  1876)  measurements  as  un- 
doubtedly too  large.  The  anterior  capsule  e(iuals  0.022—0.0.30;  whereas  his  own 
measurement  of  normal  capsules  of  small  rabbits  at  anterior  pole  e»iual  0.007.5 
—  0.009  mm.,  and  in  a  large  rabbit  6.J  years  old.  equals  0.018  mm.  In  the  fol- 
lowing table  the  relative  thickness  of  capsules  is  taken  as  one.  and  though  some 
slight  errors  may  exist,  tlie  general  results  can  not  be  entirely  ignored.  They 
show  that  tlie  thickness  of  the  new  lamellae  steadily  increases  with  the  age  of 
the  cicatrix,  whereas  the  old  lamellae  steadily  grows  thinner.  Further,  tlie  in- 
crease is  greater  in  the  beginning  than  later  on.  and  similarly,  the  old  lamellae 
diminish  more  rapidly  in  the  beginning  than  later  on. 


Age  of  the  Cicatrix. 


weeks 


10 

^Yz  months. 
(5 

]0>4        " 
;^      years. 
3      "      " 


£ntirh  Cai'SULE. 


0.028 
0.0094 


0.0188 

0.012 

O.OOW 

0,01  ];? 
o.oist? 

0.013 

0.034f) 

0.013 


Absolute  Thickness. 


Old. 


New. 


Punctured  with  a  Dis- 
ci.sion  Needle. 
0.026    mm.  10.002    mm. 
jO.0177     "    10.0017     " 

Punctured  with 
1  a  Knife. 

0.0155  mm.  10.0033  mm 
0.009  "  0.002  " 
0.0004  "  !0.003 
O.OOHI)  "  0.0047  " 
0.0117  "  0  008  " 
0.0065  "  0.00(55  " 
0.0075  "  0.030 
0  008       "     0.035       " 


Relative  Thickness. 


Lamellae. 


Old. 


New, 


Punctured  with  a  Dis- 

cision  Needle. 

0.93  mm.   j  0.07  mm. 

0.82     "      !  0.18     " 

Punctured  with 

a  Knife. 

0.82  mm.   |  0.18  mm. 

0.75     ".     :  0.25     " 

0.69     "         0.32     " 


0.59     " 

0.41 

0.60     ' ' 

0.40 

0.50     " 

0.50 

0.20     •• 

0.80 

0.19     " 

0.81 

Schirmer  says:  "Either  the  anterior  surface  of  the  cajisule  undergoes 
a  steady  resorption,  or  it  undergoes  a  steady  shrinkage:  liem-c.  every  ca])- 
sular  lamella  whicli  is  excreted  witliin  a  certain  lengtli  of  tinu",  in  its  turn, 
with  advancing  age.  becomes  thinner."  Tlie  lii'sl  supposilion  rec|uires  that 
witliin  a  certain  periodoftime, a  certain  (|nanlity  of  caiisulai- suhstanceshould 
be  restored,  and  in  a  conlinnoiis  and  icgiilai-  manner,  niiiil  linally  it  in  turn 
entirelv   disappcais;  bul    lliis  can    nd    l>c   proven,      'i'lie   theory  of  shrink- 


(ii.<ap|)c 
age  has  in  its  favoi-  ihc  fa 


ha 


nin-:  this  is  greater  than  later 


45 
on,  and  also  that  tin-  new  is  iirodiiccd  iiHirc  r.i|ii(lly  at  the  Ix'^iiin'm;:-.  always 
presupposing  that  the  ciicrizv  of  llic  i'|iitlifliiiiii  to  piodiicc  cap-ular  sul)- 
stance  remains  the  saiiu'.*" 

Changes  in  the  piiysical  properties  aceompaiiy  the  al)t)vc  changes, 
as  evidenced  by  the  edges  of  the  injured  capsule  rolling  up  outwardly.  Even 
where  free  movement  is  guaranteed  by  suspension  in  an  iudifl'erent  fluid, 
the  same  eversion  takes  place.  This  same  fact  \\a>  proven  where  fine  sec- 
tions of  fresh  capstde.  obtained  by  the  freezing  microtome,  were  exposed 
to  the  digestive  process.  Jii  both  alkaline  and  acid  solutions  the  capsule 
invariably  turned  up  outwardly,  and  it  was  iuij)ossible  to  be  mistaken,  the 
epitheliuiu  being  an  accurate  guide.  During  this  process  of  digestion,  he  ob- 
served (under  high  powers  of  the  microscope)  exceedingly  fine  and  closely 
arranged  striations.  running  parallel  to  the  surface,  in  the  beginning  con- 
fined to  the  innermost  portion  of  the  ca])sule.  Gradually  minute  inter- 
spaces began  to  develop  in  the  inner  lamella,  due  to  se])aratiou  of  the  mi- 
nute lamellae,  and  this  process  gradually  extended  more  antei-iorly.  After 
a  time  these  interspaces  grew  so  coarse  as  to  give  the  impression  of  a  verita- 
ble network,  and  thus  slowly  the  inner  layers  were  digested  before  the  outer 
were  affected  by  the  digestive  i)ower  of  the  t^py^^in.  Similar  pictures  were 
obtained  by  placing  the  capsule  in  nitric  acid,  and  then  heating  wth  per- 
manganate of  potash  or  lime  water.  This  also  will  explain  the  figures 
which  Bobinski  ^^  observed  on  surface  preparations  treated  with  nitric  acd, 
and  which  he  described  as  ''L'Capsule  Corpuscles."  and  as  analogous  to 
those  found  in  the  cornea. 

E.  Bergeri^  demonstrated  the  lamellar  construction  of  the  lens  cap- 
sule before  this  time  by  a  difterent  method.  He  satisfied  himself  by  "teas- 
ing" the  capsule,  and  by  maceration  in  permanganate  of  potash,  that  the 
torn  edges  are  not  like  straight  lines,  but  zig-zag  or  step-like,  lie  observed 
that  we  must  distinguish  at  least  three  lamellae,  although  many  sections 
led  him  to  believe  that  there  were  more.  Schirmer  states  that  he  got  his 
best  results  after  macerating  for  several  days  in  a  one-tenth  ]>er  cent,  solu- 
tion, or  in  a  ten  per  cent.  XaCl  solution.  He  succeeded  in  this  way  in  dem- 
onstrating at  least  five  lamellae,  and  does  not  coincide  with  Ik-rger's  view 
that  the  outer  lamella  is  a  zonular  lamella.  He  says:  '•Certainly  the  zonular 
fibres  are  only  attached  to  the  outer  lamella,  since  they  can  be  followed  for 


18  Tntersuchnnsen  ubor  die  Au.c;on  llnsenkapsel.  Berliner  Klin.  Wochen- 
schrift.  ISSC.  Bd.  No.  12,  p.  71. 

19  Bemerliungen  uber  die  Linseii  Kapsel  Ilirschlterjr's  Contralblatt  fur  Prak, 
Augenli.,  1882.  Beitrage  zur  Anatoniie  der  Zonvd:i  Zinni.  iiraete  Arcli..  1882. 
Vol.  XXVIII.  Alth.  2.  p.  28. 


46 

a  certain  distance  into  tlie  substance  of  the  capsule;  but  this  is  not  a  rea- 
son for  looking  upon  it  as  something  essentially  different  from  the  other 
lamoUac,  and  it  does  not  seem  justifial)le  to  attribute  to  it  a  different  struc- 
ture. \']\vn  Meeker-^  states  tliat  "he  iiever  succeeded  in  determining  by  a 
striation  the  exact  point  at  which  the  the  zonula  fibres  are  inserted  into 
the  capsule."  "Hence,  if  we  must  abandon  this  view,  the  other  two  lamellae 
can  demand  no  further  consideration  as  preformed  structures."  Schirmer 
looks  upon  the  nuicoration  experiments  as  pointing  to  the  same  conclusions 
as  the  digestive  experiments;  namely,  "that  these  delicate  lines  indicate  a 
previous  solution  of  continuity,  or  that  the  epithelium,  as  tlie  result  of 
some  external  iniluence,  has  suffered  a  serious  interference  in  its  excretory 
power,  of  which  these  lines  are  an  expression,  and  that  these  lines  move 
more  anteriorly  the  longer  the  time  since  the  injury.  Disturbances,  as  per 
example  a  wound,  the  formation  of  a  capsular  cataract  or  a  widespread  de- 
generation of  the  epithelium  in  consequence  of  a  contusion,  lead  to  an  ir- 
regularity in  the  disposition  of  the  excretory  substance,  the  optical  expres- 
sion of  which,  on  cross  section,  is  fine  lines.  The  older  a  lamella  of  cap- 
sular sul)stance  becomes,  the  more  these  irregularities  sink  in  the  back- 
ground, and  the  entire  capsular  substance  forms  a  compact  mass,  and  it  is 
only  after  long  reaction  by  the  above  method  that  these  striations  are  dis- 
closed. This  explanation  excludes  the  assumption  of  a  chemically  different 
lamellar  cement  substance." 

Schirmer  does  not  attempt  to  give  the  causes  for  these  irregularities 
in  the  life  of  the  epithelium,  but  suggests  that  it  is  a  continuous  process, 
repeating  itself  innumerable  times,  like  the  alteration  of  day  and  night,  or 
sleeping  and  waking.  He  says  he  has  observed  not  less  than  seventy-five 
lines  in  the  inner  fifth. 

The  capsule  also  has  the  property  of  elasticity.  Even  Becker  drew  at- 
tention to  tliis.  in  cases  of  luxated  lenses,  stating  "where  the  equatorial 
diameter  of  the  lens  is  reduced,  no  folds  appear."  As  the  lens  grows,  the 
capsule,  which  originally  encompassed  a  smaller  space,  increases  in  size  by 
expansion,  and  adapts  itself  to  a  greater  surface.  Even  after  the  lens  has 
attained  its  full  size,  the  individual  capsular  lamellae  as  they  are  pushed 
forward  expand,  since  the  outer  surface  of  the  capsule  is  greater  than  the 
inner.  This  curling  up  outwardly  of  the  capsule  is  an  expression  of  dif- 
fei-ence  in  Ihe  elasticity  of  the  various  lamellae. 

Tlir  cheinical  conditious  of  the  ])osterior  ca]isule  are  siuiilar  to  those 
of  the  anterior. 

Schiniicr  r»'ii<)rts  mii  intcicslinf;-  (-aso.  in  which  :i  iiiuce  of  tlii>  :interior  o:ii)sule 

20  Anatomie,  p.  43. 


47 
■was  i'Xlract«'d  lliiv*'  years  lu-fore  tlu-  I'xaiiiiualioii.  In  iliis  h-ns  ho  foimd  a 
wound  of  the  posterior  capsule,  which  the  coudltlons  present  led  him  to  believe 
was  an  old  one,  dating  back  to  the  time  of  the  operation.  Here  he  found  no 
sijrn  of  new  formed  posterior  capsule,  nor  had  cicatricial  tissue  formed,  there 
beinji:  no  epithelium  coveiinj;  posteriorly. 

At  tlic  present  dav  the  Zonula  of  /inn  is  generally  conceded  to  con- 
sist of  a  system  of  nicridianally  placed  lil)res.  which  take  their  origin  in 
the  vitreous  lamellae,  which  cover  the  par>  ciliaris.  ihc  ciliary  body  and  ita 
processes,  as  far  forward  as  to  where  these  latter  go  over  to  form  the  root 
of  the  iris.  The  fibres  are  made  up  of  innumerable,  very  fine  and  exceed- 
ingly delicate  fibrillae,  wliich  arc  iiitc  ilacc(|  in  the  most  complex  manner, 
and  it  is  this  intricate  structure  which  forms  the  suspensory  ligament  of 
the  lens.  It  is  no  longer  looked  upon  as  a  membranous  formation,  con- 
sisting of  two  plates  enclosing  "Petit's  Canal;"  hence,  this  latter  has  lost 
its  identity,  and  is  now  looked  upon  as  a  part  of  the  posterior  chamber. 
Henle  21  believed  that  these  fibres  were  held  together  by  a  cement  substance, 
which  could  not  be  demonstrated  after  death.  But  as  Czermak  has  so 
aptly  remarked,  the  interspaces  between  the  fibres  are  everywhere  much 
wider  than  the  thickness  of  the  fibres,  and  further,  no  sign  of  a  membrane 
has  ever  been  observed  under  the  microscope;  therefore,  he  considers  thia 
a  network  and  not  a  membrane.  Secondly,  if  the  fibres  w^ere  held  together 
by  a  cement  substance;  does  it  not  seem  strange  that  it  should  disappear 
so  completely,  especially  since  cement  substances  everywhere  else  in  the 
body  are  acted  upon  entirely  different  by  hardening  fluids;  as,  per  example, 
the  neuralgia  which  becomes  hardened? 

Czermak  (page  28)  has  done  more  to  elucidate  this  subject  than  any 
other  investigator.22  He  describes  the  origin  and  insertion,  in  substance, 
as  follows:  "The  delicate  fibrillae  take  their  origin  in  the  ^dtreous  lamellae, 
and  run  together  like  pencils  of  rays  to  form  coarser  fibres;  these  in  their 
turn  form  bands,  and  in  their  course,  as  they  proceed  toward  the  capsule  of 
the  lens,  they  give  ofl'  to  and  take  up  fibrillae  from  neighboring  bands,  so 
that  the  bands  do  not  grow  smaller.  The  points  of  origin  and  insertion 
vary.  They  begin  to  develop  posteriorly  about  l.-")  mm.  from  the  orra  ser- 
rata,  and  as  they  proceed  forward  they  form  acute  angles,  the  convexity 
of  the  course  facing  anteriorly:  but  before  the  fibres  reach  the  ciliary  body 
they  begin  to  split  up  again,  some  of  tlie  fibrillae  inserting  themselves  again 
into  the  vitreous  lamellae  of  the  orbiculus  ciliaris;  others  proceed  onwaixl, 
insert  themselves  into  the  vitreous  lamellae  covering  the  ciliary  body;  others 


21  Handbuch  der  Anatomie.  1866. 

22  Zur  Zonula  frage  Graefe  Arch.,  Vol.  XXXT.  B.  T.  18S5. 


48 

again  go  to  the  ciliaiT  processes,  while  tlic  niiijority  pass  onward  to  the 
capsule  of  the  lens.  At  the  same  time  fibrillae  originate  along' all  theso 
respective  parts,  each  in  its  turn  sending  out  fibrillae  to  neighboring  parts 
and  to  the  main  bands,  which  are  on  tlieir  way  to  the  capsule  of  the  lens. 
This  explains  why  it  is  that  on  nieridianal  section  one  sees  fibres  crossing 
in  all  directions.    He  has  divided  these  fibrillae  into  three  groups:"' 

First.  Those  which  spring  from  the  orbiculus  ciliaris  and  from  the 
ciliary  body  and  extend  to  the  anterior  and  posterior  capsule  of  the  lens, 
the  OrUcvlo  and  Cilio  Capsular  Fibres.'' 

"Second.  Those  fibres  which  spring  from  the  orbicularis  ciliaris  and 
again  become  inserted  more  anteriorly;  others  again  wliich  insert  them- 
selves into  ciliary  processes,  the  Orhinilo  Ciliari/  Fibres." 

"Third.  Those  which  spring  from  the  interspaces  lietween  the  ciliary 
processes  on  their  w^ay  to  Join  others,  and  those  which  extend  from  one 
ciliary  process  to  another,  the  Inter  and  Intra  Ciliary  Fibres.'' 

Hence,  each  of  the  coarser  fibres  contain  fine  processes  from  each  oC 
the  other  varieties,  more  especially  of  the  first  two,  whereas  the  forme- 
give  off'  the  fibrillae  to  neighboring  bundles.  Thus  a  most  intricate  and 
perfect  network  is  formed.  As  the  fibres  approach  the  lens,  they  again 
split  up  into  the  very  finest  fibrillae,  which  are  gradually  lost  as  they  be- 
come merged  in  the  outer  lamellae  of  the  capsule.  A  partial  crossing  of 
fibres  takes  place,  some  of  the  most  anteriorly  situated  giving  off  fibrillae 
which  go  to  the  posterior  surface  of  the  lens,  and  vice  versa.  The  fibres 
have  peculiar  sharp  contours,  are  smooth,  and  appear  like  hyaline  or  glass 
threads." 

Not  alone  do  these  fibres  form  a  suspensory  ligament,  by  means  of 
which  the  lens  is  supported  in  its  proper  position  and  relation  to  neighbor- 
ing parts,  but  owing  to  its  peculiar  construction,  it  exerts  an  equal  degree 
of  tension  in  all  directions.  This  network  of  fibres  is  the  intermediate 
member  which  ])crmits  of  the,  })roper  inci'case  or  reduction  of  tension  dur- 
ing the  act  of  accommodation. 

CHAPTER  III. 

THE  PHYSIOLOGK  AT;  IJl^TROGKESSION  Ol-;  THE  LEXS  AND  ITS 
ELEMENTS. 

The  phenomena  and  changes  which  take  place  during  the  physiolog- 
ical retrogression  of  the  lens,  are  not  I'cstricted  to  any  special  period.  Strictly 
speaking,  they  begin  as  early  as  the  third  ])t'riod  of  foetal  life,  and  undoubt- 
edly can  l)e  demonstrated  as  soon  as  physiological  growth  begins.  They 
take  place  in  tlu'  cells  as  well  as  in  the  fibres.    They  are  subject  to  the  same 


49 

laws,  as  art'  tlu-  (^|)iliiclial  crlU  ol'  ihc  ~kiii  and  iiiii((iii>  iiicinbraiies,  which 
likewise,  in  iiit raiitei-iiie  life.  Idse  their  iniclei.  are  east  olV  aiul  are  I'ound 
in  llie  veriiix  (•ase()>a  and  aiiiiiiolie  lliiid.  In  llie  lens,  however,  since  the 
capsule  is  a  closed  sac.  the  cells  are  not  east  oil'.  l)ui  (juite  the  contrary,  the 
young  growing  fibres  press  tlie  older  ones  toward  the  center.  There  they 
are  subjected  to  various  physical  and  chemical  changes,  which  lead  to  the 
formation  of  a  nucleus  and  the  cortex. 

As  soon  as  the  intelligence  of  the  child  is  siitruiently  developed  to 
permit  of  making  the  ])roper  experiments,  it  can  l)e  shown  that  there  is  a 
gradual  decrease  in  the  accommodation,  wiiich  is  a  functional  proof,  that 
a  ])rocess  of  hai-dening  is  going  on  in  the  center  of  the  lens,  whicli  influ- 
ences the  power  of  the  lens. 

These  changes  in  the  lens  are  of  a  chemical.  ])liysical  and  morpho- 
logical nature. 

The  MORPHOLOGICAL  changes  have  been  the  subject  of  the  mo^t 
exhaustive  studies,  and  have  been  most  beautifully  described  in  the  so 
often  quoted  monograph  of  Henle.  His  examinations  have  been  made 
amongst  all  the  various  classes  of  vertebrates.  In  reptiles  and  birds  and 
most  fishes  he  found  that  the  fibres  gradually  diminish  in  width.  In  other 
classes  he  found  that  the  width  of  the  libres  gradually  diminish  from  with- 
out inward,  but  this  process  does  not  proceed  as  regidarly  as. in  birds;  and 
aside  from  this  there  is  frequently  a  reduction  in  the  number  of  fibres,  ow- 
ing to  the  gradual  merging  together  of  entire  rows.  In  his  observations 
on  the  len^ses  of  man  aiid  many  animals,  Henle  ol)sevved  ^  that  the  fibres 
could  be  divided  into  three  groups.  ''Whereas,  as  a  rule,  the  fibres  dimin- 
ished in  size  towards  the  center,  there  is  pushed  in  between  an  outer  and 
an  inner  layer  of  prismatic  fibres,  a  layer  of  ribbon-like  cells,  so  that  at  some 
distance  from  the  perijjhery.  the  thickness  of  the  fibres  is  considerably  and 
rapidly  reduced,  and  then  again  as  they  ap])roach  the  center  again  in- 
creased." Henle  looks  upon  this  as  a  constant  condition  found  in  the  len^ 
of  man,  and  states  that  "it  is  not  the  result  of  an  irregular  growth,  but 
due  to  subsequent  alteration  in  the  full  grown  fibres."  But  he  gives  no 
reason  for  such  a  regular  condition.  Xot  only  the  width  and  thickness  of 
the  fibres  diminish,  but  the  edges  a])pear  serrated.  If  we  were  to  peel  off 
layer  after  layer  of  an  adult  lens,  until  it  were  reduced  to  foetal  size,  one 
woidd  expect  to  find  all  the  fibres  resembling  those  which  are  on  the  surface 
of  a  foetal  lens:  this,  however,  is  not  the  case.  Even  in  the  foetal  lens  one 
meets  with  the  same  successive  changes  as  observed  in  the  mature  lens. 

According  to  Henle,  these  serrated  edges  fit  into  those  of  neighboring 


iZur  Anatoniie  der  Krystalline.  p.  ;VJ.     (Jottingon.  1.ST8. 


50 

cells  and  those  serve  to  hold  the  individual  layers  together.  He  supposes  that 
these  serrations  are  outgrowths  from  the  fihres.  Becker  suggests  that  this 
is  rather  an  evidence  of  the  death  of  the  cell  corresponding  to  similar 
changes  in  the  cells  of  the  Kete  Malphighi  of  the  skin  and  in  the  corneal 
epithelium,  in  which  the  younger  cells  rarely  or  never  show  any  signs  of 
serration.  This  seems  to  indicate  that  these  serrations  are  due  to  shrink- 
age. It  has  been  proven  that  as  we  proceed  towards  the  centre,  the  cells 
diminish  both  in  width  and  in  thickness,  hence  what  wotild  appear  more 
natural  than  that  these  serrated  edges  are  the  result  of  shrinkage  of  the 
fibres. 

DEATH  OF  THE  XUCLEI  OF  THE  LEXS  FIBRES.  As 
has  already  been  stated,  as  the  cells  elongate  along  the  equator,  the 
nuclei  also  gradually  change  their  shai)e  from  the  circular  to  the  elip- 
tical.  They  become  longer  and  flatter,  so  that  it  does  not  become  necessary 
to  assume  an  increase  in  the  volume  of  the  nuclei.  The  form  and  size  re- 
mains about  the  same  in  all  grown  fibres.  They  all  show  tJie  karyokinetic 
changes  when  preserveil  in  the  proper  fluids.  As  we  proceed  towards  the 
centre,  the  structures  begin  to  fail.  The  chromatic  substance  runs  together 
into  one  or  more  clumps,  until  finally  it  entirely  disappears,  lentil  the  fibre 
has  attained  its  full  length  the  nucleus  retains  its  life-like  appearance.  Bui 
as  soon  as  a  fihre  extends  from  one  ratlins  of  the  star  figure  to  another,  the 
nucleus  legins  to  shoio  signs  of  death.  This  can  be  observed  in  the  lens  of 
the  new-born  infant,  and  is  true  of  every  ])eriod  of  life. 

THE  PHYSICAL  CHANGES  which  tJie  individual  (iln-es  undergo 
with  increasing  age,  consist  of  an  increasing  hardness  and  yellowish  color, 
and  an  increasing  index  of  refraction.  The  hardness  becomes  manifest  by 
the  resistance  ofl'ered  to  pressure  when  a  specimen  is  under  the  cover  glass. 
The  yellow  color  becomes  evident  when  a  number  of  lamellae  are  super- 
imposed one  upon  the  other.  All  these  changes  are  due  to  the  giving  up 
of  water,  leading  to  greater  dryness  and  friability  of  the  inner  layers,  partly 
however,  also  as  a  result  of  chemical  conditions  of  the  older  fibres. 

That  there  is  a  ehcniical  difference  between  the  inner  and  the  outer 
portions  of  the  lens  seems  to  be  attested  by  a  fact  which,  though  known 
for  a  long  time  and  frequently  discussed,  has  been  variously  accounted  for; 
namely,  that  in  the  lenses  of  all  vertebrates  and  young  animals  which  dur- 
ing life  have  been  ])erfec11y  transjiarejit,  immediately  after  death,  as  soon 
as  the  animal  jjecomes  cDld,  the  inner  portion  of  tlu'  lens  becomes  cloudy. 
Michel  2  drew  attention  to  the  fact  and  showed  thai  the  cloudiness  in  the 


2  "Uber  naturliflu'  uiid  ktinstliclic  Liiist'iitiul>un.ineuV"  Ft>stschrift  znr  Feier 
des  300  Yaliri.iffii  Brstchcii  dcr  .Iiiliiis  Mnxiiiiilius  UniviTsitatc  zur  Wurzliurg, 
1S82. 


5' 
colli IV  of  the  Ions  of  oats,  ])iK>.  inid  oalvo.-,  would  (li>n|)|.oar  again  if  they 
wore  v.arniod  up  to  L",  to  20  do.uroos  C.  This  could  bo  repeated  a>;  often 
as  desired,  and  each  time  the  lens  would  clear  up  again.  This  cloudiness 
is  produced  by  the  presence  of  innumerable  roundish,  highly  refracting 
droi)iots  in  the  central  portions  of  the  lens,  and  is  not  in  any  way  <-on- 
nectod  with  the  decomposition  of  the  contents  of  the  lens,  such  as  is  pro- 
duced by  freezing  (/.  c,  p.  ()2).  In  these  experiments  there  can  not  ari^e 
any  (luestion  as  to  the  separation  of  the  water  from  the  albumin.  These 
droplets  become  less  numerous  as  we  go  from  within  outward.  Treated  with 
alcohol  and  ether,  their  number  becomes  less,  and  they  are  reduced  in  size. 
Hence  it  appears  that  they  must  consist  of  a  fatty  substance,  which  has  a 
very  low  melting  point,  though  it  is  impossible  to  state  anything  more  def- 
inite at  this  time.  The  interest  which  the  appearance  of  these  bodies  at  h 
low  temperature  arouses  is  duo  loss  to  their  })rosenco  than  to  the  fact  that 
they  occur  in  the  inner  lamallae  of  the  lens,  that  their  numl)or  varies  in 
different  species  of  animals,  and  that  their  deposit  ceases  a  few  months  after 
birth.  From  this  ^t  follows  that  in  the  chemical  formation  of  the  lens, 
especially  in  the  older  layers  of  the  same,  very  pronounced  changes  take 
place.  Since,  according  to  Kuline  and  Laptschinsky.  the  amount  of  fat  is 
greater  in  the  old  than  in  the  young,  hence  it  can  not  be  due  to  a  quanti- 
tive  but  rather  to  a  qualitative,  change. 

Various  authorities  have  drawn  attention  to  the  fact,  that  the,?e  de- 
scribed changes  in  the  lens  keep  pace  with  the  physical  and  morphological 
changes  which  take  place  from  the  center  toward  peripheiy.  Some  of  the 
pecuharities  of  the  peripheric  lamellae  are  in  accord  with  this.  From  year 
to  year  the  nuclei  in  the  nuclear  zone  become  less  numerous;  the  nuclear 
zone  comes  loss  near  to  the  axis,  its  curvature  grows  less;  in  other  words, 
the  number  of  smooth,  non-changod  lens  fibres  which  roach  to  the 
lens  star,  grows  less  year  after  year. 

In  the  capsular  epithelium  the  cliangos  (\\\q  to  the  age  are 
less  marked,  luiuinu'rablo  moasuroments  have  shown  that  the  diam- 
eter of  the  base  of  the  oi)itlielial  cells  remains  almost  the  same 
during  life,  at  least  as  long  as  thoy  rolain  tlioir  sliapo.  Xot  so. 
however,  with  the  height  of  the  cells.  Beginning  at  a  point  corresponding 
to  the  pole,  the  ])ase  of  the  coll  gradually  grows  loss,  whereas  at  the  begin- 
ning of  the  whorl  the  cell  is  about  three  times  as  high  as  it  is  wide.  In 
course  of  time  the  height  of  the  cell  at  the  pole,  as  well  as  along  the  equa- 
torial region,  gradually  diminishes,  and  sections  taken  from  very  old  people 
show  the  height  of  the  cell  to  be  that  of  the  niulous.  whereas  the  protoplasm 
between  the  nuclei  is  shrunken  to  an  almost  immoasural)le  thickness.     In 


52 

some  sections  some  of  the  luu-lei  ;ire  round  wanting  and  some  cells  ai-e  en- 
tirely -wanting.  Xothing  conld  he  moi'c  wonderful  than  the  regularity  with 
which  the  perfectly  circular.  O.UO.j  mm.  in  diameter  nuclei  are  found  in  the 
epithelium  dispersed  over  the  capsule  of  young  lenses. 

Examinations  of  unstained  spcciiiit'iis  show  iK-nutifully  the  nndcai-  fij;ures 
at  rest:  whereas  staiiunl  witli  Ilaciiioti.x.vliii  and  I-:(>siii.  tliese  liiiiires  show  less 
distinctly:  with  .Vluni  ("ni-niiu  lliey  are  somewhat  more  distinct.  The  (nitlines 
of  the  cells  are  likewise  more  distinct  in  the  unstained  sections.  The  proto- 
plasmic bodies  touch  and  limit  each  other,  as  most  exact  liexagoual  figures. 
In  some  exceptional  cases  tlie  contours  of  the  cell  bodies  take  the  stain  as  do 
the  nuclei,  reminding  one  of  Arnold's  "indigo-carmin  ledges."  Wlien  the  stain- 
ing is  done  rapidly  witli  a  concentrated  Haemotoxylin  solution,  some  of  the 
nuclei  take  on  a  darker,  more  pronounced  stain  tlian  others.  These  always 
are  a  measureable  trifle  longer  than  the  paler  nuclei,  or  they  sliow  a  tendency 
to  form  star  figures.  Fre(iuently  tlie  nuclei,  in  the  vicinity  of  one  of  these 
darker  cells,  form  a  circle  around  it,  or  the  dark  nucleus  appears  as  the  head 
of  a  spiral  whicli  is  formed  on  succeeding  10-15  nuclei.  As  a  result  of  this  ai'- 
rangement  the  surface  of  tlie  capsule  covered  witli  tlie  epithelium  assumes  a 
perfectly  regular,  almost  life-lilve  appearance.  It  is  more  than  proijal)le  that 
these  nuclei,  which  take  the  stain  more  deei)ly,  were  just  al>out  to  undergo 
nuclear  division  at  tlie  time  the  sections  were  placed  in  Muller"s  fiuid. 

.\s  we  approaeli  tlie  eiiuator  tlie  niU'lei  grow  smalli'r.  ai'e  jiacked  closer  to- 
getlier,  take  the  stain  more  deeply  than  tlie  surface  preparations.  In  older  in- 
dividuals Hearing  the  fortieth  year,  the  picture  changes,  in  so  far  that  the 
deeply  stained  cells  grow  less  in  number,  as  do  also  these  peculiar  circles  and 
spiral  figures.  From  noAv  on  tlie  distinctly  stained  nuclei  and  cells  grow  less 
and  less,  but  never  entirely  disajipear.  In  extreme  old  age  it  often  happens 
that  on  pieces  of  capsule  the  epithelium  is  found  wanting  for  certain  distances; 
here  undoubtedly  either  the  epithelium  remained  adherent  to  the  lens  or  dropped 
off  during  the  manipulations  incident  to  staining,  dehydrating,  etc.  "  AVhere  cap- 
sules hai-dened  in  :Muller's  fluid  are  sliaken  in  water,  whole  sections  of  capsular 
epithelium  may  lie  detaclied,  ;nid  liere  frequently  tlie  capsule  sliows  the  im- 
pressions wliere  tlie  cells  w<'re  adherent.  Tliis  is  due  i>r(>l>:ihly  to  the  cement 
substance  of  the  ejiitliellal  cells,  1  »eu1schm;urs  subcaiuilar  layer,  which  has  re- 
mained adlierellt    to  tlie  ca]>sule. 

Again,  here  and  there,  cells  are  found  wanting  or  changed  into  \'esicular 
Cells.  At  times  Iliey  form  veritable  nests.  It  is  remaiUalile  how  little  coloring 
matter  is  taken  up  liy  llie  nuclei  of  tlie  cells  and  by  Ihe  c:ii)suie.  irres]iective  of 
.■ig<'.  .Xevertlieless,  Die  nuclei  tjikc  uji  Ihe  st;iin  in  a  more  regul:ir  manner  tlian 
do  these  distended  cells.  If  tliese  latter  .-ire  to  he  looked  upon  .-is  dying  or  de.-id 
cells,  then  we  mu.st  accejit  :i  second  v.iriely  of  death  of  the  nucleus.  In  other 
sections,  at  tinii^s  one  Muds  large  numliers  of  nuclei  Just  about  to  die.  just  as 
noted   ill    tiie   lens   tibres.      ,\g:ii]i.    one   notes   cells   of    ihe   cajisular   epithelium 


which  arc  still  pcrfoct  in  contour,  showing:  nuclei  un-catly  rcihiccd  in  volume, 
and  which  take  the  stain  <1.m'i»1.v.  as  noted  in  tihres  in  wlij.li  tin-  nuclei  :ire  just 
about  to  disappear. 

CIIAPTHli   IV. 

TIIK  IMIVSiUl.()<;Y  OK  Til  JO  I.KXS  SVSTKM. 

THE  M'ANXER  OF  ITS  XOUKISHMENT  IN  IIK.M/I'll   AXD 
DISEASE. 

TIIK  DIRECTIOX  AXD  COURSE  OF  TIIK  XUTRITIVE 
STRF.\:\[  IX  TIIF  EEXS.  Tlie  1oti.<  is  ciKloscd  in  a  structure- 
less meiii1)raiie.  wliicli  under  normal  conditions,  is  not  permeabk' 
to  formed  elements.  Fntil  near  tiie  close  of  embrj'onal  life,  a  vas- 
cular membrane  is  closely  applied  to  this  structureless  capsule.  Be- 
yond a  doubt,  the  vessels  of  tliis  membrane  serve,  during  the  developmental 
period,  to  supply  the  nutritive  material  to  this  hyperplasia  and  increasing,' 
growth  of  the  cells  and  the  fibres  within  this  capsule.  After  tlie  degenera- 
tion of  this  vascular  capsule,  we  are  confronted  by  the  peculiar  condition, 
namely,  that  the  lens  is  only  indirectly,  by  means  of  the  zonula  fibres,  held 
in  connection  with  the  firm  portions  of  the  eye.  And,  further,  since  the 
zonula  fibres  contain  neither  nerves,  blood  vessels  nor  lymph-channels,  the 
lens  must  receive  its  nutritive  supply  either  from  the  aqueous  or  vitreou.=, 
possibly  from  both.  These  media  likewise  possess  neither  nerves  nor  blood 
vessels.  It  is  just  possible  that  the  iris  stands  in  relation  to  this  interchange 
of  fluids,  since  the  pupillary  edge  is  merely  separated  from  the  anterior 
capsule  by  a  capillary  layer  of  fluid. 

Such  being  the  conditions,  the  question  to  be  determined  was,  along 
which  lines  does  the  nutritive  fluid  gain  entrance  to  the  lens?  In  his 
Pathologic  and  Therapie.  p.  2ru,  Becker  expressed  his  belief  that  "the 
nutritive  stream  gained  entrance  in  the  equatorial  region,  between  the  two 
leaves  of  the  zonula,  because  pr()l);ibly  along  this  line,  under  normal  circum- 
stances, the  new  formation  of  cells  and  ])ositively  the  growth  of  fibres 
^'progressed  most  actively."  Deutschman  ^  investigated  this  subject  more 
closely.  He  gave  a  rabbit  one  gnu.  of  pot.  iodide  in  solution  and  three 
hours  later  killed  the  rabbit.  The  lens,  enclosed  in  its  capsule,  was  placed 
in  a  palladium-chloride  solution  and  was  proven  to  be  impregnated  with  the 
pot.  iodide  and  most  intensely  along  the  sub-capsular  albuminous  layer 
of  the  posterior  ca])sule.  as  well  as  along  its  entire  eijuator.  to  a  less  degree 


1  Cataracts  Senilis,  3879.     Graefe  Arch..  Bd.  XXV.  L'.  p 


54 

the  siib-nipsuliu-  layer  xmdev  The  anterior  capsule,  but  disclosed  no  sign  of 
impreo-nation  in  the  nucleus  or  anterior  corticalis.  Here  should  be  inci- 
dentally menlioned  tliat  he-  also  observed  that  if  he  opened  the  lymph 
sac  in  salt-water  frogs  and  in  this  lymph  sac  placed  crystals  of  chlor 
natrium,  the  cataract  which  resulted  was  due  to  the  extraction  of  water. 
Hence  Deutschnian  considered  it  as  very  probable  that  the  nutritive  stream 
entered  along  Petit's  Canal.  Ulrich  ^  arrived  at  the  siime  conclusion  as 
the  result  of  the  following  experiments.  He  injected  ferro-cyanide  of 
potash  sub-cutaneously  and  subsequently  placed  the  eyes  in  a  solution  of 
chloride  of  iron  alcohol,  lie  states:  "The  line  along  which  the  ferro- 
cyanide  of  potash  gained  entrance  to  the  lens  could  only  be  detected  by  the 
stain  along  the  line  of  the  equator;  the  posterior  capsule  of  the  lens  re- 
mained unstained.  The  experiments  which  Schoeler  and  Ulitlioff  mada 
according  to  Ehrlich's  methods^  by  using  fluoresein,  led  them  to  gven  a 
more  advanced  conclusion,  stating,  "Under  physiological  conditions  (by 
sub-cutaneous  injection)  the  fluid  reached  the  equator  of  the  lens,  ex- 
clusively through  Petit's  Canal.  Xever,  however,  does  the  fl.uid 
go  directly  through  the  vitreous  to  the  lens.  Further,  the  colored  fluid 
which  has  once  been  taken  up  by  the  lens  is  never  given  off  again  througli 
the  vitreous." 

Samelsohn  came  to  a  positive  opinion  as  to  the  line  along  which  the 
interchange  of  tissue  fluids  occurs,  by  observing  the  changes  which  took 
place  in  three  lenses,  in  each  of  which  a  minute  spicule  of  iron  had  become 
impacted  in  the  lens.  In  all  of  these  he  observed  that  the  particles  of  rust 
always  changed  their  position  in  the  same  manner.  In  summing  up  his 
conclusions,  he  states,^  "It  appears  that  the  principal  direction  of  fluids  i>i 
directed  from  behind  forward  and  on  reaching  Petit's  Canal  becomes 
'dammed  up'  (Ulrich)  along  this  line:  it  also  gains  entrance  to  the  lens 
along  the  lino  of  the  equator.  I'rom  here  on  it  traverses  the  entire  lens 
centripetally  and  comes  together  again  at  the  antei'ior  pole;  from  here 
it  again  goes  out  centrifugally  toward  the  insertion  of  the  Zonula  fibres, 
where  it  leaves  the  lens  and  enters  the  posterior  chamber." 

Along  the  line  where  the  nutritive  fluid  is  supposed  to  leave  the  lens, 
Samelsohn  assumes  the  presence  of  special  pores  in  the  capsule,  which  offer 


2  Deutschman— riitcisueliungou    zni-    rathogenese    dor    ('ataract.      Arch.    f. 
Ophthal.,  Bd.  XX 11 1,  p.  117. 

3  Uber  die  Kninln-uug  dcs  Angcs  Cnicfc's  Arch..  Bd.  XXVI.  ?,.  p.  ;'.:^-82. 

4  Das  Fluoresein  in  seiner  Bedoutinig  fur  den  Flussiiilvcitswccliscl  dos  .\uges, 
Yahresbor  der  ScholtM-isclien  Augon  KJinik,  1S81. 

5Zur    Fhissig-kcitssln.inuiig   in   dcr    Linsc     Zclicnd.Ts    Mon.Mtshl..    I'.d.    XIX. 
p.  282. 


55 
the  least  j)ossil)lo  liiiulraiiee  to  the  I'scape  of  the  used  lliiid  uliirli.  Iiuw- 
ever,  are  not  sufficiently  wide  to  jiermit  the  passage  of  formed  elements. 
The  pores  are  the  same  as  those  which  Morano  *•  believes  he  saw,  l)ut  which 
no  one  else  up  to  the  })ivsent  time  has  seen. 

riilricirs  ("Stauuii,i;s  thcoi-ic")  "(laimiiin^-  hack"  tlicorv.'^  on  which 
Saniclsohii  ])ascs  hi>  slatciiicuts.  reads  as  foHows:  "'rhc  most  intense  hhio 
color  of  the  vitreous  (and  in  fact  the  most  intense  in  the  entire  globe  which 
can  be  attained  l)y  the  use  of  sub-cutaneous  injections  of  ferrocyanide  ot 
potash)  develops  in  the  region  of  the  ecpiator  of  the  lens.  The  liltration  of 
tissue  fluid  out  ol'  the  vitreous  proceeds  from  tiie  vitreous  honler  into 
Petit's  Canal  aiul  on  reaching  its  anterior  wall  it  again  meets  with  a  de- 
taining filter,  the  free  portion  of  the  Zonula  of  Zinn,  which  likewise  shows 
a  blue  discoloration.  As  a  natural  result  of  the  placing  of  two  parallel 
filters  in  the  region  of  the  equator  of  the  lens,  there  must  naturally  follow 
a  damming  back  of  the  streams  of  fluid.  This  detention  is  more  favorable 
to  the  nutrition  of  the  lens,  since  it  takes  place  at  the  eqmitor,  where  the 
space  is  very  limited,  and,  further,  since  the  iris,  which  will  receive  further 
consideration  later  on,  acts  as  a  third  i^arallel  filter."  Without  going  any 
further  into  Uhlrich's  views  concerning  the  individuality  of  the  posterior 
chamber  as  compared  with  the  anterior,  and  his  views  concerning  the 
passage  of  fluid  through  the  iris  from  behind,  forward,  it  is  nevertheless 
proper  to  refer  to  the  investigations  of  Deutschman,^  in  which  he  states 
"that  in  a  certain  sense,  or  under  certain  conditions,  the  iris  acts  as  a  pro- 
tective organ  to  the  periphery  of  the  anterior  surface  of  the  lens." 

In  all  that  has  so  far  been  stated,  attention  has  only  been  drawn  to  Those 
experiments  in  Avhich  coloring  matter  was  given  the  animal,  either  per  os  or 
subcutaneously.  Only  these  seem  to  possess  demonstratable  proof.  But  this 
is  not  the  only  reasons  why  Knies'  investigations  have  not  been  cited  before 
this.  In  his  critical  studies  relative  to  the  Nutrition  of  the  Eye  lo  he  arrives  at 
anatomical  conclusions,  with  whicli  Becker  does  not  agree.  Knies  states  (page 
340*):  A  form  of  cataract  which  begins  in  the  Equator  shows  to  us  as  a  neces- 
sity that  there  is  an  affectation  of  a  portion  of  the  Uveal  tract,  which  is  situ- 
ated anteriorly  to  the  Orra  Serrata  and  posterior  to  the  anterior  lamellae  of  the 
Zonula  of  Zinn,  namely,  of  the  pars  eiliaris  choroideae  and  the  processes  ciliares. 


einterno  agli  stomi  dell  end  otlialio  della  capsula  del  cristallino  Atti  dell 
associar.  Ottal  Ital  Rianione  di  Napoli,  Settembre,  lS7i>,  p.  61. 

7Uber  die  Ernahrung  des  Auges.     Graefe's  Arch.,  Bd.  XXVI.  3.  p.  41. 

8  Die  Veranderungen  der  I>inso  in  Eiterproceoson  im  Auge.     Arch.  f.  Opth., 
Bd.  XXVI,  1,  p.  144. 

9  Becker  says,  page  92. 

10  Arch.  F.  Augenlieil-kunde,  Bd.  VI 1.  p.  320. 


56 

Tliis  is  true  of  the  ordinary  senile  cataract,  and  at  the  bottom  of  pajre  341  he 
says:  "Let  us  consider  the  lens  and  ciliary  processes  as  far  as  the  nutrition 
physiologically  is  concerned  as  a  single  organ,  etc."  These  ciliary  processes, 
however,  are  external  and  anterior  to  the  Zonula  Zinii,  and  the  latter  is  be- 
tween the  ciliary  processes  and  the  e(iuator  of  the  lens,  which  even  Knies 
concedes  to  be  the  line  of  entrance  for  tlic  nutritive  stream  of  the  lens.  The 
ciliary  processes  form  the  secretory  organ  for  the  ;i(iutM.us  humor.  .Mud.  as  it 
appears,  have  nothing  whatevci-  to  do  with  the  nutrition  of  the  lens,  or  at  most 
only  secondarily. 

Becker,  in  his  essay  on  the  nuclear  zone  of  the  lens,  drew  attention  to  a 
heretofore  not  mentioned  condition  of  the  lens  capsule  of  youthful  individuals, 
wliich  he  tries  to  l>ring  in  conui'ctiou  with  the  entrance  of  nutritive  fluid.  He 
states:  "The  capsule  is  materially  thickened  at  a  particular  point  which  lies 
posterior  to  the  Equator."  I  have  formerly  observed  a  similar  thickening  of 
the  capsule  in  secondary  cataracts,  which  I  also  attributed  to  this  swelling,  and 
which  I  have  attempted  to  bring  in  connection  Avith  the  rapid  increase  in  the 
size  of  the  cells  during  the  formation  of  the  Crystalline  Pearl.  This  would  seem 
to  indicate  that  the  abnormal  conditions  which  had  resulted  from  an  operation 
had  caused  an  especially  active  nutritive  stream  to  pass  through  the  capsule, 
and  thus  cause  the  capsule  to  SAvell  up.  It  is  possible  that  analogous  changes 
could  occur  in  uninjured,  rapidl.v-growing  lenses,  but  as  to  whether  this  change 
takes  place  during  life  must  remain  an  unanswered  question.  Assuming  this 
to  be  a  post  mortem  swelling,  occtirring  after  the  specimen  has  been  placed  in 
harclening  fluid,  this  observation  Avould  not  be  without  interest,  since  one  is 
justified  in  concluding  that  a  different  condition  existed  in  the  capsule  at  this 
point,  even  during  life.  "This  point  of  thickening,""  he  states  with  great  cer- 
tainty, '"is  j)osterior  to  the  i)()sterior  limit  of  Petif  s  canal."  How  long  after  birth 
this  peculiarity  of  the  capsule  of  the  lens  i»ersists.  and  whether  it  is  in  any 
way  connected  Avith  the  retrogressive  formations  of  the  vascular  capsules  of 
the  lens,  I  can  not  state,  owing  to  lack  of  available  material.  It  was  still  per- 
ceptible in  the  capsule  of  a  seven-weeks'  old  child. 

Even  in  fully  developed  cataracts  one  ma}^  demonstrate  the  existence 
of  a  nutritive  stream.  This  was  proven  long  ago  by  the  beautiful  experi- 
ments of  lienee  Jones  ^^.  In  a  number  of  experiments  on  animals  to  whom 
a  large  variety  of  substances  were  given  via  the  digestive  tract  and  by  sub- 
cutaneous injection,  at  a  later  date  he  deiuojistrated  beyond  a  doubt  tlieir 
presence  in  the  lens.  TJkewise.  in  a  number  of  experiments  on  human 
beings  and  animals,  whicli  were  given  carbonate  of  lithia,  in  a  few  minutes 
this  could  be  found  in  every  part  of  the  body,  but  it  required  thirty  to 
thirty-two  minutes  before  it  appeared  in  the  lens.     Cataract  patients  to 

11  Proceedings  of  the  Tloyal  Institute  of  ({real  r.rit:iin.  Vol.  IV.  Part  VI, 
No.  42,  October. 


57 

whom  'iO  ui'iiiuiiics  of  lilliia  \v;is  jiivcii  in  Wiilci'.  niid  w  lio  wci-c  hilcr  operated 
on  by  P)o\vma.n  and  Critelictt,  llic  lilliia  was  loimd  in  cvci}  |iai-t  of  the 
lens,  when  the  extraction  was  done  Iwo  and  a  lialf  to  three  hours  after  ihe 
infjestion  of  tlie  lithia  water.  Allei-  foni-  (hiys  lilliia  was  still  found  in  all 
parts  of  the  lens:  after  live  days  it  het^an  izradiially  to  disappeai'.  and  after 
seven  days  it  was  scarcel\  pos>il)le  to  denion>lrate  a  trace  of  lithia  in  the 
extracted  lens. 

The  attempt  has  heen  made  to  prove  by  this  and  a  W'w  iie<;ative  experi- 
ments, that  the  interchange  of  nntritive  fluid  is  an  e.\ceedin>:ly  slow  one. 
Ulricli  has,  as  it  appears  with  jierfect  j'ight.  di-awn  attention  to  the  fact 
that  this  conclusion  is  not  Justifia])le.  if  one  will  only  sto))  to  compare  the 
nutritive  conditions  of  tfie  non-vasculai-  lens  with  other  vascular  tissues. 

Schlosser '-  looked  upon  the  spindle-sha|)ed  intersiiaces  around  the 
nucleus  of  the  lens  as  a  veritable  system  of  lymph  channels.  His  investiga- 
tions were  all  made  where  pathological  conditions  were  present,  and,  as  we 
shall  see  further  on,  these  splits  are  a  pathological  production  and  therefore 
invalidate  his  conclusions.  He  states.  "In  the  normal  lens  these  peri- 
nuclear spaces  are  few  and  very  narrow,  whereas  in  cataractous  lenses  they 
are  widely  dilated."  "The  spaces,"  he  says,"  follow  the  direction  of  the 
iibres."  He  bases  his  conclusion  on  the  above-quoted  views  of  Samelsohn, 
stating  ''that  the  nutritive  stream  enters  the  lens  along  the  equator,  thence 
proceeds  to  the  center  of  the  posterior  cortical  substance  and  to  the  posterior 
star  figure  and  reaching  the  peri-nuclear  canals,  flow  toward  the  anterior 
star  figure,  finally  converging  toward  a  circular  area  l)eneath  the  anterior 
capsule,"  which  he  considers  the  line  of  exit. 

At  the  time  the  Xaphthalin  experiments  were  first  ]u"actieed. 
it  was  hoped  that  they,  by  the  pathological  processes  which  followed  in  the 
lens,  would  shed  some  light  on  this  still  interesting  question.- but  this  hope 
has  not  been  realized.  A  large  number  of  investigations  were  made  by 
Bouchard  and  Chnrrni}--  Paniias}'^^  Dor}^  ('.  Hcss^^^  Mdi/iiiis.^^^  Kol- 
Unshi,^"^  and  Prof.  Hugo  Magnus. i-"^**     The  last  named  concluded  that  the 


12  Uber  die  Lymphbalnien  der  Linse.     Munclieiier  Med.  VVochenschrift,  No. 
7,  1889. 

13  La  semanie  medicalle.  1880.  No.  .",2. 

13a  Ktudes  sur  la  nutrition  de  I'oeil   dapres  des   exiuTiences   faitos  avec  la 
flourescine  et  le  Napthalin  Arch.  Opth..  1887.  Mars  Avril. 

14  Bulletins  et  memories  de  la  societe  Francaise  d  Optli.  1887.  p.  150. 
Ha  Berichte  idier  llttli   \'ei-saiuluuK  der  Opth.  (Jes.'l.     Hci(icll)erjr.  1887. 
lib  Therapeutische  .Moualschi-ift,  October.  1887. 

15  Zur  lehre  von  der  Wirkins  des   Naplialins  nwf  das   .Vnuc   uiid   uber  den 
Sogenanten  Napthalin  staar.    r.raefe  Arch..  XXX\'.  H.  L*.  issii. 

15a  Experimentelle   Stndien    niter   die    lOriialiniui;-   der    Ki'ystalline   uiid   uber 
Cataract  Bildung. 


5« 

nutrition  of  the  lens  could  be  interft'ivd  witli  as  the  result  of  interference 
wilh  the  eirculation  of  nutritive  iiiiids  in  tlu'  leus  or  l)y  clianges  in  the 
ehemieal  condition  of  tlie  nutritive  fluids  of  tlie  lens.  Ife  concludes  "(1) 
that  the  nutritive  ])roeesses  <ro  (Ui  more  actively  and  in  a  more  complete 
2nanner  in  the  posterior  half  of  the  lens.  (2)  A  zone  posterior  to  the 
equator  and  running  parallel  to  this,  appears  to  take  up  a  greater  nutritive 
stream.  (3)  A  zone  anterior  to  the  equator  of  the  lens  and  running  parallel 
to  this  also  appears  to  take  up  nutritive  fluid,  hut  to  a  less  degree.  (4)  The 
posterior  pole  likewise  takes  u])  a  nuti'itive  stream,  which  is  still  less  than 
the  two  just  mentioned,  (o)  Nutritive  fluid  does  not  appear  to  he  taken  up 
at  llie  anterior  ])ok'.  ((>)  The  e(|uator  of  the  lens  itself  does  not  take  u])  a 
separate  nutritive  stream,  but  is  dependent  on  the  two  zones  anterior  and 
posterior  and  removed  from  it.  (7)  The  manner  in  which  the  nutritive 
fluids  escape  from  the  lens  is  still  unknown." 

THE  PHYSICAL  CHANGES  which  the  lens  undergoes  as  the  indi- 
vidual advances  in  age.  and  under  pathological  conditions,  affects  its 
vohni/c  and  ircif/hf.  its  hardness  and  dn/ness,  its  r(dor]pssness.  its  transpa- 
rriici/.  and  it.<  iitdox  of  refraction. 

The  gradual  increase  in  iveight  and  volume  is  a  necessary  result,  due  to 
the  continuous  formation  of  new  fibres  at  the  equator,  which,  under  normal 
circumstances,  is  scarcely  ever  interrupted,  even  up  to  advanced  age.  Thi? 
is  beautifully  illustrated  in  Priestly  Smith's  table  on  page  31.  The  exce]> 
tion  to  this  rule  he  found  in  lenses  which  began  to  show  even  slight  cata- 
ractous  cloudiness.  Having  weighed  these  with  especial  care,  he  found 
that  at  the  beginning  of  the  process  the  cataractous  lenses  had  a  reduced 
volume  (and  weight)  as  compared  with  non-cataractous  lenses  of  the  same 
age.  Therefore,  we  are  indebted  to  Priestly  Smith  for  the  valuable  knowl- 
edge relative  to  the  study  of  the  cataract,  namely,  that  a  reduction  of 
volume  precedes  the  formation  of  calaracl. 

Owing  to  the  giving  off  of  water  from  its  innermost  lamellae,  and 
which  process  gradually  progresses  toward  the  periphery,  the  lens  becomes 
dryer  and  harder  from  within  outward.  Nucleus  and  cortex  are  prin- 
cipally difl'erentiated  by  this  difference  in  hai-dness. 

Loss  of  colorh'f<sness  accompanies  the  above  changes.  As  early  as  tlie 
twentieth  yeai-.  the  yellowish  tinge  begins  to  numifest  itself.  This  change 
continues  gradually  to  increase  as  long  as  the  lens  remains  transparent,  but 
this  progress  is  not  always  an  equally  progressive  one.  We  must  either 
assume  that  this  discoloration  is  not  of  the  same  intensity  in  all  cases,  or 
that  the  chemical  changes  are  of  a  different  character  in  different  indi- 
viduals. Whereas,  at  times  we  meet  with  very  aged  individuals  whose 
lenses  show  but  a  very  slight  yellowish  discoloration,  we,  on  the  other  hand, 


59 

meet  with  tlie  so-ealled  Calaract  yii/ra.  in  wliicli  llic  coloi-  of  the  lens  is  .^o 
dark  and  its  transparency  so  far  iiupaii'cd,  iluit  vision  is  reduced  to  the 
greatest  degree,  so  that  one  is  forced  lo  rciiidxc  tliis  non-calararlous  /c/zs- 
by  operative  procedure. 

It  would  scarcely  seem  necessaiT  to  slate  thai  diii'ini:-  llic  I'drmalioii  of 
calaract  the  transparency  of  tlic  lens  is  greatly  intei-fered  with.  f'Jrery 
o/xicili/  (if  l/ie  lens  ayaicm,  is  culled  ii  (liri/  Cdhinirl.  hi  Senile  Cata-  . 
rncL  llic  inilial  nparilies  are  Jiie  lo  rJietinciil  chdiiyex  in  Hie  slni/nienl  /Inids 
ir/iir/i  orrnjiies  llir  i  nlerspdees:  llie  fibres  serondarlli/  heeoine  cliiudy 
due  lo  cheniicdl  dcann pusilion  iind  llie  nierhaniral  disinlc'/ralion.  In  the 
soft  cataracts  of  the  young  and  in  most  consecutive  cataracts,  we  find  that 
after  the  taking  up  of  aqueous  inside  of  the  capsule,  the  first  opacities  in  the 
lens  fibres  are  due  to  the  formation  of  vacuoles. 

The  hyperplasia  of  capsular  epithelium  is  perfectly  transparent  in  the 
beginning  (Knies).  It  is  only  later  on.  after  tlie  structure  becomes  organ- 
ized, that  it  loses  its  transparency.  In  all  probability  the  large  vesicular 
cells  (yet.  to  be  considered)  occur  in  transparent  lenses.  They  only  lead  to 
opacities,  when  they  undergo  hyaline  (or  colloid)  degeneration,  which  does 
occur  vei-y  soon. 

According  to  all  former  assumption.  Hie  cliani/e  in  llie  index  of  re- 
fraction of  the  lens  was  explained  in  the  following  manner:  As  age  advanced, 
instead  of  there  being  a  steady  increase,  from  periphery  to  centre,  there  is 
a  gradual  decrease,  and  the  lens  is  gradually  merged  into  a  homogenous 
body  having  the  index  of  refraction  of  the  nucleus.  After  Helmholtz  had 
shown  that  a  homogenous  transparent  body  having  the  form  of  the  crystal- 
line body  and  possessing  the  index  of  refraction  of  its  nucleus  (hence  the 
very  greatest  which  the  nornuil  lens  possesses)  will  have  a  much  smaller 
total  index  of  refraction  than  the  combination  of  the  various  lamellae  of 
the  youthful  lenses,  each  of  which  possesses  a  different  index  of  refraction, 
the  attempt  was  made  ^^  to  explain  the  gradual  transition  of  the  emmetropic 
eye  to  the  hypermetropic,  as  age  advances,  as  due  to  the  gradual  transition 
of  the  lens  into  a  more  homogenous  body.  l>ut  Becker  states  that  he  has 
not  been  able  to  find  an  experimental  demonstration  of  the  fact  that  the 
difference  in  the  index  of  refraction  of  the  individual  lamellae  of  the  lens 
is  less.  Priestly  Smith  ^^  gives  a  different  explanation' of  this  reduction  of  re- 
fraelion  in  the  aged.  He  states:  "The  continuous  growth  of  the  lens  suf- 
ficed to  explain  the  acquired  hy]>ermeiroi)ia  of  old  age,  witlKuit  assuming 
that  the  lens  changed  its  form. 


16  Donders— Anomalies  of  Refraction  and  Aooommodatioii.  180(5. 

17  Growth  of  the  Lens.     Mod.  Times  and  Gaetto.  .January  20.  1883. 


6o 

This  subject  has  ivci-ntly  been  investigated  by  L.  Heine.**  He  used 
the  eyes  of  liimian  corpses,  in  which  the  refractive  conditions  were  deter- 
mined by  skiasopy  before  death.  Subsec^uently,  he  found  that  the  radkis 
of  curvatiire  of  the  anlei'ior  surface  of  the  lens  had  not  changed;  but,  on 
severing  all  the  zonular  fibres,  the  radius  of  curvature  at  the  anterior  pole 
was  increased  to  such  a  degree,  that  the  radius  in  the  latter  condition  was 
to  the  former  as  6  to  10.  Similar  experiments  in  old  people  did  not  show 
an  increase  in  the  radius  of  curvature.  In  the  eye  of  a  corpse  the  radius  of 
curvature  at  the  anterior  pole  of  the  lens  is  13  to  14  mm.,  whereas,  after 
severing  all  the  zonular  fibres,  the  radius  is  reduced  to  8-10  mm. 

In  determining  the  index  of  refraction  of  the  lens,  an  Abbe's  refracto- 
metre  was  used:  and  the  estimates  were  based  on  Matthiessen's  ^^  general 
formula,  that  the  tofol  index  of  refraction  of  a  lens,  consisting  of  equally 
centric  lamellae,  is  as  much  greater  than  the  index  of  the  centre  of  its 
nucleus,  as  the  difference  between  the  latter  and  the  index  of  its  cortical 
substance.  In  other  words,  the  total  index  of  refraction  is  obtained  by  find- 
ing the  index  of  the  substance  at  the  anterior  pole;  also  of  the  nucleus;  and 
adding  the  difference  between  the  two  to  that  of  the  nucleus.  The  index 
of  refraction  found  in  the  lens  held  tense  by  zonula  fibres  was  looked  upon 
as  the  ?ion-accommodating  lens;  whereas,  with  all  fibres  cut,  this  was  con- 
sidered as  the  accommodating  lens. 

The  index  of  refraction  of  substance  obtaiued  at  iuiteriov  i)()lf 1.390—1.395 

Tlie  index  of  refraction  of  isolated  accommodntiug  lens 1.380—1.385 

The  index  of  nucleus 1.408—1.410 

Estimated  from  these  figures: 
The  index  of  refraction  of  entire  lens  during  act  of  acconnnodatiou.  .1.435—1.440 
The  index  of  refraction  of  entire  lens  at  rest 1.42.5—1.4.30 

iVs  long  as  the  zonula  is  held  tense,  an  albuminous  body  is  found  at 
the  anterior  pole  of  the  lens,  which  has  a  lower  index  of  refraction.  This 
produces  an  increase  in  ihc  total  index  of  refraction.  As  a  result,  during 
the  act  of  accommodation,  the  refractive  coiulition  is  in  part  covered 
(1-3  D).  The  change  in  the  coutour  of  the  lens  is.  nevertheless,  the  main 
factor  in  producing  an  ahered  relVai-tive  condition. 

It  was  noted  that  the  older  the  individual,  tlir  liiglicr  the  index  of  re- 
fraction at  the  anterior  jioh — the  values  gnulually  iiureasing  fnuu  1.395 
to  ].I0.").     The  index  of  the  nucleus  likewise  iiu-reases.  hut   not    to  such  a 


aKeitrage  /nr  rhysiologie  und  I'.ithologio  der  Ivinse.  Graefe  Arch.,  Vol. 
XI.VI.  Part  3,  r.  52.-..    189S. 

18  Zehender.  Matthiesen  and  .Tacobson.  IJber  die  Breehuugscoetficient  Kat- 
aractoser  Liusen  substanz.  Zeliendor's  Klin.  Monatsbl.,  Bd.  XV,  p.  237-311.  Ze- 
hender's  Klin  Monalsblntter,  Kd.  XVII,  p.  307. 


6i 

(loo-roo.  (at  most.  O-OOo).  'riicri'loiv.  tlif  total  index  of  llic  -ciiilc  Icii-  is 
iimcli  less  than  in  the  yoiillirul  lens.  The  valiio  of  senile  len>  i-an.i:c' 
rroin  1.415  to  1.425 — and  hence  it  innst  appeal-  evident  thai  thi>  ivdnced 
index  of  refraction  causes  the  hy|iei-ii|)ia  >>['  did  a,i:e.  .No  donhl  the  general 
increase  in  tliic-kness  of  the  lens  may  compensate  for  this,  within  certain 
limits. 

'I'Ih'  I'olh.win--  is  a  Schematic  tahle  nf  the  avera-e  total  indices  of  re- 
iVaction: 

Senile  hyinn-opia 1.41."i 

rresbyopia.  doi)en<]in.ii-  on  the  ajio  and  lliickuess  of  lens 1.420  -1.42.J 

Youthful   lenses 1 .480 

Leuses  during  act  of  aceoniniodation 1.440 

N.  r>.— In  the  schematic  eye  a  chanji-e  of  (ine  in  the  second  decimal  i>laco 
chans'os  the  total  index  of  refraction  Vjl>  (equals  iL>  mni.  difference  in  optic 
axi.s). 

In  cataraetons  lenses  the  indt'x  of  refraction  is  nearly  always  found 
increased.  This  may  be  due  to  various  causes:  First,  the  anterior  pole  may 
disclose  an  ahnormally  low  index:  this  would  increase  the  total  index.  Sec- 
ond, the  nucleus  may  be  very  markedly  sclerosed,  and  Hius  the  index  may 
be  increased.  Third.  l)oth  conditions  may  he  combined,  in  the  first 
group  belongs,  possibly,  the  mature  catai-act.  the  ^lorgagni's  and  soft  cat- 
aracts in  which  the  nucleus  is  sclerosed:  in  the  second  group  aiv  found 
mature  cataracts  and  certain  forms  of  diabetic  cataracts,  in  which  irregular 
sclerosis  and  softening  has  not  as  yet  destroyed  the  structure  of  the  lens. 
Thus  can  be  explained  the  clinical  observation,  thai  at  times  during  the  in- 
cipient stages  of  cataract  formation,  myopia  develo[)s. 

THE  CHEMISTRY  OF  THE  LENS  AND  THE  FLUID  MEDIA 
WHICH  SUEKOHND  IT. 

With  the  exception  of  the  increase  in  weight  and  volume  of  the  trans- 
parent lens,  all  the  above-described  changes  are  dependent  on  the  chemical 
changes  which  take  place  in  the  lens.  These  in  their  turn  will  he  largely 
dependent  on  the  constitution  of  the  nutritive  supply  which  is  ol)tained 
from  the  vitreous. 

That  very  marked  chemical  ditl'ei'ences  exist  hetween  the  lens  of  the 
young  and  those  advancing  in  age  has  already  heen  pointed  out.  (on  page 
51),  on  the  evidence  of  anatomical  proof. 

Our  knowledge  of  the  chemical  constitution  oi  the  crystalline  lens  is 
inseparable  from  the  nann^  of  J'x'iv.clius.  In  the  o\"s  lens  he  found  an 
albuminous  substance  like  his  glohulin.  which  he  mimed  Kri/slallinr.  It 
appears  that  human  lenses  were  not  sulnnitted   to  a  (piantitative  analysis. 


62 

According  to  Kuliiie.-*^  Ihc  lens  coiitiiiiis  water  (iO  per  cent.,  albuminous 
material  37.5  per  cent.,  fat  and  traces  of  cholesterine  2  per  cent.,  and  ashes 
at  niost  0.5  per  cent.  Later  analyses  are  from  the  laboratories  of  Hoppe 
Sevier.  Laptschinsky,^!  as  the  average  of  the  analysis  of  four  cahes'  lenses, 
gives  the  following:  Water  03.51  per  cent.,  albuminous  material  34.93  per 
cent.,  lecithin  0.23  per  cent.,  cholesterine  0.23  per  cent.,  fat  0.29  per  cent., 
soluble  salts  0.53  per  cent.,  insoluble  salts  0.29  per  cent. 

Whereas  Kuhne,  like  Simon,  Alex.  Schmidt,  Liebei-kuhn  and 
Vintschgau.  states  that,  after  careful  trituration  in  sand,  extraction  in 
water  and  filtration,  he  obtained  a  faint  opalescent  fluid,  in  which  he  found 
at  least  three  albuminous  bodies,  globulin,  kali  albumin,  and  serum  al- 
bumen, Lapiscliinsl-ij  ol)tained  no  precipitate  from  the  clear  filtrate  of  the 
precipitated  globulin  which  he  dissolved  in  a  weak  acid,  whereas  the  solu- 
tion became  cloudy  at  55  degrees  and  at  70  degrees  showed  a  flaky  coagu- 
late. Therefore,  according  to  the  latter,  the  lens  does  not  contain  a  potas- 
sium albuminate,  but  merely  a  globulin  (24. G8  per  cent.)  and  serum  al- 
bumen (10.31  per  cent.).  Cahn  ^^  triturated  fresh  animal  lenses  (accordin'^ 
to  Hammarsteu's  method)  with  crystallized  magnesium  sulphate  and  after- 
wards washed  this  out  with  a  saturated  soda  magnesium  solution,  during 
which  process  more  of  the  albuminous  substance  was  taken  up  by  the  solu- 
tion. l^\om  this  he  concluded  that  the  entire  lens  was  made  up  of  a 
globuline.  He  adds:  "Whether  or  not  this  is  a  single  one  is  yet  to  be  de- 
termined." Prof.  Michel  and  Henry  Wagner  ^s  investigated  this  subject 
again.  They  concluded  that  at  least  in  the  pig's  eye,  also  in  the  ox's  eye, 
we  find  lento-glohuline  and  lento-albumim.  To  digress  here  for  a  moment. 
Michel  24  has  made  some  very  interesting  experiments  relative  to  the  tem- 
perature within  the  eye-ball,  and  with  special  reference  to  its  action  on  the 
crystalline  lens.  With  a  peculiarly  constructed  electrical  thermo  element 
he  made  a  series  of  investigations  in  the  eyes  of  rabbits.  The  temperatur<i 
in  the  rectum  was  38.5  degrees  C,  the  average  in  the  anterior  chamber 
was  31.9  degrees  C,  and  in  the  middle  of  the  vitreous  36.1  degrees,  which 
he  also  considers  to  be  the  average  temperature  in  the  centre  of  the  lens. 
In  the  anterior  chamber  the  temperature  fell  several  tenths  of  a  degree, 
when  the  point  of  the  instrument  was  brought  close  to  the  cornea,  whereas 
it  rose  proportionately  as  it  approached  the  iris,  almost  attaining  the  tem- 

20  Physiological  Chomie,  p.  404.     lieipsig,  1868. 

21Ein  Beitrag  zuv  Cliomie  des  Liusongewbos.    Pflugers  Arch.,  Bd.  XIII,p.C31. 

22  Zur  Physiol,  and  Pathol.  Chemie  des  Auges,  Strassburg,  1881,  p.  17. 

23  Physiol'ogische  Chemisf4ie  Untersuchungen  des  Auges.     Prof.  Met.  D.  W. 
Graef  Arch..  XXXII,  Boole  2,  ^^.  ir>r.,  1880. 

24  Die  Temperature  Topogiaphi«'  des  Auges.    Graefe  Arch.,  Vol.  XXXll,  B. 
2.  1886. 


63 
peratniv  in  llio  viti-cuus.  A^inin.  in  tlio  vitreous  (lie  tcniperaUiro  iiuTeaseO 
as  the  instiiuiirm  ncarcd  \hv  coals  of  the  eve.  and  attained  the  hody  tem- 
perature when  ilii'v  wei-e  loiiclitwl.  'I'lic  tciii|icrai lire  increased  2.3  defrree> 
when  the  lids  were  elosed  and  on  llif  apjilicaiion  of  an  iec  bag  the  tem- 
perature fell  13  to  1.')  degrees  ( '.  in  tlie  e(Uir.-e  ot  one  and  a  half  minutes. 
The  relatively  low  teini)erature  of  the  anterior  chamber  may  be  due  to 
the  rapid  dissipation  of  lieat  by  the  cornea;  also  due  to  the  fact  that  the 
blood  vessels  are  relatively  far  removed.  This  latter  cause  may  also  explain 
the  low  temperature  in  the  centre  of  the  vitreous.  From  a  physiological 
standpoint  these  temperature  conditions  appear  to  be  especially  important, 
since  undoubtedly  they  exert  a  very  decided  influence  on  the  albuminous 
bodies  in  the  eye,  especially  in  the  lens.  Michel  gives  the  following  experi- 
ment. If  a  small  ice  bag  is  laid  on  the  eye  of  a  cat.  a  total  cloudiness  of  the 
lens  will  follow  in  a  short  time,  which  will  again  disappear  shortly  after 
the  ice  bag  is  removed. 

It  would  hardly  seem  necessary  to  remind  one  of  the  therapeutic  value 
of  the  above  experiments,  which  show  the  rapid  changes  in  the  temperature 
due  to  closure  of  the  lid,  or  the  application  of  an  ice  bag. 

Laptschinsky  found  that  the  amount  of  the  cholesterine  varies  greatly, 
ranging  from  0.06  per  cent  to  0.49  per  cent.  He  also  found  that  the  normal 
transparent  lens  contains  lecithin. 

Our  interest  is  especially  directed  toward  discovering  the  differences 
in  the  quantities  of  water,  albuminous  material,  also  lecithin,  found  in  the 
senile  7ion-cataractous  and  in  the  senile  cataradous  /e/(.spv. 

Water.  Deutschman  ^s  demonstrated  for  the  no/i-cataractous  lens,  that 
which  up  to  this  time  had  been  accepted,  but  which  never  had  been  experi- 
mentally proven,  by  weighing  human  lenses  removed  from  the  body  shortly 
after  death,  and  then  permitting  them  to  dry  out  completely,  and  in  this 
w^ay  he  succeeded  in  demonstrating  as  a  fact,  that  though  there  is  a  general 
increase  as  age  advances,  there  is  a  diminution  both  absolute  as  well  as  rela- 
tive to  the  weight  of  the  entire  lens  (from  70.8  to  64.6  per  cent.)  of 
the  amount  of  luater  contained,  whereas  the  amount  of  ilrij  constituents 
increases.  Naturally,  there  were  differences  in  the  weight  of  the  different 
lenses,  as  well  as  in  the  relation  between  the  amoimt  of  water  and  the  dry 
constituents  of  the  lens.  The  weight  of  five  senile  cataracts,  four  of  which 
had  been  extracted  by  H.  Pagenctacher,  and  the  fifth  was  a  cataracta  incip- 
iens  and  had  been  taken  from  a  corpse,  showed  (p.  216)  that  the  senile 
cataractoiis  lens  contained  considerably  more  water  (r6.23  per  cent,  as  op- 
posed to  69.06  per  cent.) //m/i  the  non-cloudy  senile  and  that  they  were  poorer 


25  Cataracta  Senilis,  1879.     Graefe  Arch.,  Bd.  XXV.  2.  p.  214. 


64 

in  solid  conslilucnts,  especially   the  alliuniinou.-.   products.     Both   features 
were  less  developed  in  C.  incipiens. 

Jacobson's  stateuients -^  are  at  variance  with  these,  who  fouiul  just  the 
opposite.  iKiiiu'ly.  that  (■(thuutclniix  ]rns(>s  could  in  less  water  ((!;?. 45  per  cent, 
as  oppose^]  to  7;i.ti  per  cent.)  than  the  normal.  This,  liowever.  is  due  to  the 
fact  that  Jacobson  made  his  estimates  from  lenses  which  had  Ijeen  extracted 
without  theiv  capsules,  and  hence  there  can  be  no  doubt  but  that  a  part  of 
the  watery  cortical  substance  remained  behind  in  the  eye.  Unfortunately, 
Deutschman  failed  to  state  how  his  lenses  were  preserved  while  being  trans- 
ported from  A\'iesbaden  to  Goettingen  in  order  to  protect  them  against 
alterations  in  their  watery  constituents.  Both  Priestly  Smith  and  J. 
Treacher  Collins  -"  agree  with  Jacobson.  The  latter  examined  six  fresh  eyes 
one  houi'  after  enucleation:  also  ten  cataractous  lenses,  with  following  re- 
sults:— 


Fresh  Eves,  10-64  yrs. 
Average  Total  Weight,  0.204 
Water,  .  .  0.1446=    71  per  cent. 

Solid  Constituents,       .  0.059  =29 
Ashes,  .         .         .  0.0013=0.  (5 


10  Cat AR  A 
0.113 

0.073  =    fio  per  cent 
0.040  =    35 
0.0014=1.57 


Le.nsks,  46-80  yrs. 


Collins  states:  "The  weight  of  the  cataractous  lens  is  far  below  that  of 
the  normal."  The  cataractous  lens  is  not  to  be  looked  upon  as  the  result  of 
excessive  changes  due  to  age,  but  rather  the  result  of  nutritive  disturbances 
of  an  entirely  different  nature,  chemical, 7iot  morphological. 

Albuminous  Substances.  Calin-^  analyzed  cataracts  which  had  been 
extracted  by  Laquer  without  their  capsules  and  been  subsequently  preserved 
in  alcohol,  and  he  has  compared  his  results  with  those  of  Laptschinsky 
which  the  latter  made  in  normal  calves'  lenses.  Since  these  are  the  only 
qnantitive  estimates  of  human  lenses,  they  are  quoted  here  aud  will  be 
referred  to  again  later  on: — 




100  Parts  of  Solid 
Constituents  Contain 

In  Cataracts. 

In  Normal 

I.         1         II. 

Ox  I^ENSES. 

.\lbunien,    . 

81.48 

86.87 

94.71 

Cholesterine,    , 

6.22 

4.55 

0.62 

Lecithin,      . 

4.52 

0.803 

0.63 

Fat, 

1.19 

(t.79 

.\lcoholic  Extract, 

0.83 

1.45 

0.71 

Watery  Extract, 

3.94 

2.76 

1.52 

Solualjle      \  c„itc 
Insoluable  i  °^"^'       " 

1.81 

2.41 

1.36 

1.14 

1.45 

0.46 

26Uber  die  Brechungs-coefficienten  iind  uber  die  Chemische  BeschaCfenheit 
Kntaraktoescr  Liusensnbstauz.    Zehcnder's  Klin.  ^lonatsblntl.  Bd.  XVII.  p.  307. 

27T1IO  Composition  of  the  Human  Lens  in  Health  and  in  Cataract,  etc. 
Opthalmie  Rfview,  November.  1880. 

2S  Zm-  IMiysiol.  and  Pathol.  Chemie  de.s  Angos.    Strassbm-g.  p.  18.  1881. 


65 

According  to  tlic   (wo  jiiialysos.    tlic    avcra^u    ahsulute    decrease    of 
albumen  equals  0.95  to  0.84  ])er  (ciii. 

Calm,  however,  also  had   llu'  t)|)|)()rtuiiii v   <>f  ajialy/.ini:  a   iiiiiiiIkt  of 
freshly  extracted  senile  cataracts,     lie  preserved  tlieni  in  quite  a  concen- 
trated sol.  of  coninion  salt  until  he  had  a  sufficient  number,  and  then  util- 
ized them  to  determine  the  niiidiinl  of  all)iiininous  material  in  senile  catar- 
acts by  comparing  the  results  of  that  wliicli  is  insoluble  in  water  and  CO,  to 
that;  which  is  soluble.     The  absohilc  aiuoiuil  of  albuminous  material  soluble 
in  wafer  and  CO  was  found  to  be  diminished.    Both  the  soluble  and  the  in- 
soluble albumines  were  then  dried,  and  the  average  analysis  of  the  two 
analyses  showed  tliat  the  propoi-tion  of  the  solubh^  to  the  insoluble  albu- 
mines Avas  to  that  of  the  noinial  ox  lens  as  24,  C)-i:  10,  -81:  that  is,  as  3.38: 
1  is  to  15.09:  1.     Xow,  since  as  we  have  seen  all  alt)uiniuous  substances 
which  are  present  in  the  normal  lens  are  globuline,  and  that  the  apparent 
incomplete  elimination  of  serum  albumen  is  dependent  on  the  abnormal 
quantities  of  water  and  CO^  Calm  draws  the  conclusion  from  this  fact,  that 
irhere  cataracts  are  treated  with  water  and  CO,  a  much  greater  portion  of  al- 
buminous substance  is  eliminated,  and  llial    during    life   a    portion   of   the 
albuminous  substance  has  been  so  modified  as  to  hare  become  insoluble.     It 
is  not  difficult  to  assume  that  this  rery  circumstance  adds  to  the  cataractous 
cloudiness. 

Cahn  does  not  decide  what  this  modification  is.  Becker,^^  reasoning 
by  analogy,  expresses  the  belief  that  since  the  lens,  like  the  skin  and  hair, 
is  derived  from  the  ectoderm,  keratine  might  be  found  in  the  nucleus  of 
the  senile  or  cataractous  lens.  Knies,  by  means  of  Kuhne's  digestive  meth- 
od, proved  that  this  assumption  is  not  true.so  He  also  examined  senilo 
cataracts  which  had  been  extracted  without  their  capsules:  hence,  essen- 
tially their  nuclei.  The  result  was  a  fluid  which  gave  all  the  reactions  of 
peptone,  and  did  not  in  any  way  differ  from  a  peptone  fluid  which  resulte.l 
from  digestion  of  alb^imcn.  According  to  Knies,  the  substance  of  the  nu- 
cleus of  cataract  is  albuminous  in  its  nature,  though  it  did  show  certain 
difference  in  its  chemical  relation  to  other  albuminous  substances.  This 
digestive  method  has  in  other  ways  proven  its  importance  to  the  anatomy 
and  chemistry  of  the  lens.^^  By  this  means  it  has  been  shown  that  since 
the  capsule  of  the  lens,  like  Descemet's  membrane,  can  be  completely  di- 


29  Patliolosie  Tlu'nipic.  p.  109. 

30  Knies  Zur  Chemie  dor  Alters  veranderunfren  der  T.inso.     T'ntersncli  a.  d. 
Physiol.  Inst.  d.  Univ.  Heidelberg,  Bl.  2.  p.  114. 

siKulme  and  Ewald  die  verdauuns  als  Histolosisclie  Mothode.    Yerhand  dor 
Naturhistor  Med.  Verein  in  Heidelberg.  Bd.  1. 


66 

gested,  it  is  not  an  elastic  membrane.  It  seems  to  coincide  very  much  with 
the  cement  substance  of  tlie  U'us.  In  fact,  tlie  entire  lens  may  he  digested, 
leaving  hut  a  slight  residue. 

f'holesierine  ami  Fat.  The  various  authorities  seem  to  coincide  as  to 
the  amount  of  cholc-tcj-iiu'  in  cataractous  lenses.  Kuhne^^  found  in  senile 
(human)  lenses  wliicli  Iiad  assumed  an  amber  color  a  greater  amount  of 
fat  and  cholesterine  than  in  the  normal  lenses.  Laptschinsky  (cited  above, 
page  639)  could  only  reiterate  this  statement  as  to  the  amount  of  fa.t  found 
in  cases  of  amber  colored  lenses  in  oxen.  It  is  however  questionable  whether 
Ave  can  imisiih'r  the  lenses  of  slaughtered  animals  as  senile,  in  tlie  sense 
wliich  we  consider  lenses  in  old  people  suffering  from  senile  cataract. 

A\'e  are  indebted  to  Jacobson  for  the  most  thorough  investigations  con- 
cerning the  amount  of  cholesterine  contained  in  the  human  lens  during  the 
various  periods  of  life.  This  analysis  was  made  at  the  instigation  of  Zo- 
hender  and  ]\Iatthieson.  He  found  (cited  above,  page  315)  that  the  lens  of 
a  new  born  infant  does  not. contain  any  cholesterine,  and  in  the  lens  of  a 
young  woman  of  20  years,  he  found  but  slight  traces.  He  was  the  first  to 
draw  attention  to  this  increase  in  the  cataractous  lens  (page  313).  Though 
he  had  to  make  a  partial  retraction  in  a  latter  publication  (2d  paper  cited, 
page  309),  he  nevertheless  states:  "'//(  i/oung  individuals,  as  a  class,  ilie 
amonnt  of  choleslerine  is  much  less  titan  in  individuals  wore  advanced  in 
life,  and,  as  a  ivhole,  cataractous  lenses  are  richer  in  cholesterine  than  nor- 
mally transparent  lenses.  Jacobson  (p.  308)  found  in  (U  lenses  taken  from 
individuals  under  60  years  of  age,  that  3.11  per  cent,  of  the  dry  substance 
consisted  of  cholesterine,  and  in  27  transparent  lenses  taken  from  indi- 
viduals over  60  years  of  age,  2.36  per  cent.,  and  in  86  cataracts  taken  from 
individuals  over  60  years  of  age,  2.68  per  cent.  Both  of  the  analyses  of 
Cahn  are  in  accord  with  these  figures.  As  compared  with  the  0.(i2  per  cent, 
cholesterine  (100  parts  of  solid  substance)  in  the  normal  .cortical  sub- 
stance, he  found  in  the  centre  of  the  cataract  5.38  per  cent,  cholesterine 
Jacobson  was  further  able  to  show  that  the  nucleus  of  the  cataract  contains 
three  times  as  much  cholesterine  as  the  cataract  substance.  Therefore,  he 
considers  it  as  prohabk  that  cholesteriiie  is  not  a  foreifjn  substance,  which  1$ 
carried  to  the  lens  by  the  natritire  fluid,  hut  that  it  is  rathe v  the  result  of  a 
change  in  the  allmminous  substance  contained  in  the  lens. 

Lecithin.  Laptschinsky  found  lecithiu  in  the  cortical  sul)stauc-e  of  the 
normal  lens,  as  did  also  Cahn  in  both  his  analyses,  and  in  the  last  very 
much  increased  in  quantity.  He  does  not  attempt  to  draw  any  conclusions 
from  this. 


32  Physiologisfho  Clioniic,  ISOS.  p.  400. 


67 

//■  ire  ntnr  hrir/h/  iiidhr  ii  rcsiinir  of  llir  dhorr.  wr  liiid  llnit  Dciilsrlniiait 
inrciTcd  tVoiii  the  rcdnctioii  of  llic  aWxilutc  (Hiaiil  il  \-  nl'  dried  cortical  sub- 
stance ill  cataracts,  an  al)S()liitc  rcdiiclidn  of  I  lie  alhiiniinoiis  substance  in 
cataract;  ./dcuhsoii  stalc>  that  a  ixu'lion  of  I  lie  alhniiien  lias  hccn  cliaii-i-ciE 
into  cli()lc>tcrinc.  w  licrca.-  Caliii.  as  tin'  roiilt  (if  lii>  cliciiiical  invcsli^'^ations 
of  n(in-cata!act()n>  lenses  aiul  senile  liiinian  len>es.  state>  that  in  cataract 
there  is  a  reduction  of  alhiiiiiinons  material,  partly  chan.iicd  into  an  iusol- 
uhlc  substance,  with  at  tlu'  same  lime  foi-mation  of  cholestei-ine  (and  loci- 
Ihin.  inci-ease  of  tlie  extractive  and  anorganic  substances).  '.I'hough  C-'ahn 
states  that  he  is  not  able  to  draw  any  <'onclusion  fi'om  his  i-esults  couceru- 
ing  the  cataractous  |)rocess.  liecker  draws  this  very  im|iortant  conclusion, 
that  "Ihiiuijh  (ill  (ii/rrr  as  la  llir  phi/sicdl  coinlilidd.  l/irn:  lids  nererUiclcss  been 
/inircii  llidt  llicrr  d rr  ilniidiisl nildhlt'  cliniiical  (liffrrriin's  hclirren  llir  niiiieii^ 
of  llir  noii-rloiiih/  a  ml  llic  inirlriis  of  llir  raid  nicloiis  snillr  Irns." 

A  suhstance  which  has  been  occa>ionally  noted  in  the  lens,  and  w  hicli 
does  not  occur  under  noi-nial  conditions,  is  siujar.  Its  presence  in  tlie  len>* 
iu  cases  of  diabetic-  cataract  has  attracted  the  greatest  attention.  Its  pres- 
ence bere  bas  been  utilized  as  tbe  basis  on  wbicb  to  l)ui!(l  a  theory  for  tbc 
(b'velopnu'iit  of  tbis  ])artic!ilai-  foi'ui  of  cataract.  There  may  be  various 
reasons  why  its  i)resenc-e  is  not  a  constant  one.  which  will  he  touched  on 
again,  in  order  to  ;ivoid  doiihts  wbicb  niigbt  arist'  in  tbe  minds  of 
tbe  reader  as  to  tbe  accuracy  with  w  bich  tbese  tests  were  made,  Trof.  Kulme 
kindly  permitted  the  publication  of  the  metbods  pursued  in  bis  laboratory. 
On  Marcli  !t.  ISSl.  Kuluie  exaiiiincd  for  Be<-lver  a  cataract.  Avliich  the  latter 
had  .lust  extracted.  His  h'tt<>r  reads  as  foUows:  "Tlie  cataractous  mass  Avhich 
I  received  on  .March  Utii  was  nilihed  ui>  niinutel.v  in  water  heated  to  the  boilinjn 
point,  sntticient  acetic  acid  a(hled  to  liive  it  a  weak  acid  reactlou.  Altered  while 
still  hot.  and  the  liltrate  washed  in  hoilin.ii'  water,  and  the  clear  filtrate  dried 
over  a  water  batli.  The  colorless  lirni  residue  was  tlien  boiled  witli  alisoluti- 
alcohol,  and  this  tittered  after  coolini:  left  nolliiny-  to  1>."  reduced.  After  this 
mass,  which  was  insoluble  in  ab-ohol.  had  been  furllier  extracted  in  etlier.  this 
was  dissolved  in  a  f<'W  drops  of  water,  lo  wln<-ii  were  added  a  few  drops  of 
over-proof  alcoliol:  tliis  was  lieated:  after  cocdini;  tiltered.  an<l  tlie  residue  left 
ou  the  tilter  after  evaporation  was  taken  up  anew  in  water,  and  used  in  makini;- 
Troninier's  test.  In  order  to  be  able  to  reeognize  even  tlie  faintest  reduction,  to 
the  solution  to  which  caustic  soda  had  been  added,  .lust  sufficient  sulphate  of 
copper  solution  was  added  to  jiive  the  faintest  trace  of  blu«'  color  to  the  solution. 
On  idaciim  the  lest  lul)e  in  water,  haviiii;  a  teinperature  of  SU  dejirees  C.  the 
4-olor  rapidl.v  disai»peared.  and  a  reddisli  color  developed.  Each  time,  on  cool- 
in.i;-.  a  new  (piantity  of  the  sulphate  of  copper  solution  was  a<lded.  until  tlie  bhu> 
color  was  retained  on  heatinc.  In  tlie  meanwhile,  tliere  had  been  such  a  rich 
deposit  of  reddish  crystals  of  oxidt>  of  copper,  that  it  was  possible  to  determine 


68 

that,  there  was  a  very  coiishU'rahle  <iuautity  of  siiptr  in  the  lens.  The  insolu- 
bility ol"  the  reduced  body  in  absolute  alcohol,  and  the  rapid  appearance  of  the 
reduction  at  a  temperature  beloAv  85  defrrees  ('..  were  all  jinarantees  of  the 
identity  of  this  substance  with  diahvtir  suyur. 

The  second  cataract  was  extracted  from  this  same  individual  Marcli  21»,  1881. 
and  examined  by  Dr.  Mays.  His  report  reads  as  follows:  "The  lens  was  placed 
in  boiling  Avater,  and  thus  reduced  in  size.  After  this  solution  had  been  made 
weakly  acid  by  the  addition  of  acetic  acid,  and  then  allowed  to  boil  for  a  while 
longer,  it  was  filtered;  the  filtrate  strongly  compressed,  and  alcohol  added.  Dur- 
ing the  compression  a  small  exudate  had  formed,  so  that  it  became  necessary 
to  filter  once  more.  The  filtrate  was  next  evaporated  to  dryness,  and  the  residue 
was  talien  off  in  water.  With  this  solution  the  Trommer's  tests  were  made. 
After  the  solution  had  been  made  alkaline  by  the  addition  of  caustic  soda  solu- 
tion, there  was  added  just  a  suflicient  quantity  of  a  dilute  sulphate  of  copper 
solution,  to  give  the  slightest  perceptible  shade  of  blue.  The  color  disappeared 
on  heating  in  a  Avater  bath,  without,  however,  at  once  causing  a  noticeable  de- 
posit. After  the  addition  of  several  more  drops  of  the  sulphate  of  copper  solu- 
tion, the  fiuid  retained  its  color  in  the  water  bath.  After  the  fluid  had  stood 
during  the  dinner  hour,  a  quantity  of  the  fluid  was  drawn  from  the  bottom  of 
the  test  tube  by  means  of  a  pipette,  and  examined  under  the  microscope.  The 
presence  of  a  few,  but  not  to  be  mistaken  crystals  of  the  oxide  of  copper,  proved 
that  the  reduction  had  taken  place,  from  which  one  is  justified  in  declaring  that 
sugar  was  present."  Kuhne  added  the  following  remnrks:  "According  to  the 
reduction  test  the  quantity  of  sugar  appears  to  be  less  than  in  the  cataract  which 
I  examined  on  March  9,  1881.  Since  this  difference  does  not  appear  to  be  in  the 
amount  of  oxide  of  copper  which  was  reduced,  since  this  was  not  estimated,  but 
lies  in  the  precipitated  oxide,  this  may  also  depend  on  the  presence  of  sub- 
stances which  keep  the  oxide  of  copper  in  suspension  in  alkaline  solutions. 
Such  disturbing  additions  Avere  more  certainly  excluded  in  the  method  of  ex- 
amination pursued  in  the  first  lens;  the  second  method,  though  simpler,  is  not 
to  be  recommended,  because  it  offers  us  a  less  quantity  of  material  with  which 
to  make  an  investigation. 

In  urdev  lo  decide  tliis  (ttiestion.  wliether  tlie  lens  or  a  cnlaract  does 
contain  a  sul)stanc('  which,  on  the  addition  of  an  alkaline  solution  would 
give  the  oxide  of  eopi)er  reduction.  Kuhne  was  kind  enouph  to  examine 
(for  Becker)  five  senile  cataracts  and  one  traumatic  cataract,  all  taken  from 
non-diahdic  patients,  just  as  they  chanced  to  follow  each  other  in  oper- 
ations at  the  clinic.  Such  a  sitpposition  seemed  vci'ilied.  for  Kuhne  found 
that  the  watery  extract  free  of  albumen,  taken  from  the  lens  of  a  rabbit,  had 
the  property  of  discoloring  the  copper  solution  on  making  the  Trommer's 
test,  and  at  times  minute  crystals  of  the  oxide  of  copper  were  seen  under 
the  microscope.  The  results  of  Kuhne's  examination  was  as  follows:  The 
lenses  were  triturated  in  water,  and  after  the  addition  of  a  trace  of  acetic 


69 

acid,  were  hoiU'd.  'The  lilli-;itc  \\;i>  cNjiiKU-iiicd  lo  ((Hiiiilcic  di'viicss.  iinJ 
tlie  iviiiniiis  wci-c  lakcii  up  in  alcoliol  (1).  Tli.-it  which  the  idcohol  hd'l  in- 
solul)U'  was  taken  up  in  So  pci-  ccnl.  ah'dhol  CJ).  And  the  Hiird  in-(.lnl)le 
rcinaindci-  was  taken  up  in  water  (;!).  1  and  '!  were  e\ap(irate(|  and  ehaiiji'eJ 
lo  a.  watery  xdntinn.  and  in  the  rednelion  lest  L;a\c  a  negative  ie>idt.  as  did 
also  .">.  All  thfee  jjortions  were  next  just  lui-ned  pereei)t  ihle  liliie  by  the 
addition  of  hydrate  of  soda  and  snlpliaie  of  copper  solution,  and  heated 
over  a  water  hath  I'oi-  a  considerable  len.uth  ol'  time  at  a  lein]ierat  nre  of  100 
degret's  (',  dui-in.i:-  which  the  cohjr  did  not  clian,i:e.  Later  on  tiie  eoh)r  was 
made  decidedly  hhu'  by  addition  of  inoi-e  Cn.  and  then  thoroujihly  heated 
over  a  (lame;  ])ut  at  the  end  of  iweidy-four  hours  none  of  these  tests  showed 
a  preeij)ilate  in  which  the  oxide  of  co|)])er  could  In;  tletecled  microscopically. 
These  lenses.  Ilwn-forc.  did  nut  contain  anij  sugar,  and  in  fart,  notliiii;/  irhich 
coutd  l)e  reduced. 

Armaignae -^^  observed  in  a  cataracla  ni^uni.  small,  globular  granules, 
which  he  considered  haematoidin.  The  only  speetroscopieal  analysis  so  far 
reported  was  made  hy  Gillet  de  Grandmont.^^^  He  extracted  a  very  laro-e 
black  cataract.  The  fundus  disclosed  a  general  chorio  retinitis.  The  spec- 
troscopic examination  proved  that  tlie  hlack  color  was  due  to  liver  pigment. 
The  occui'rence  of  the  fundus  disease  explains  the  pathogenesis  of  the  form 
of  cataract.  Pykalt  believed  the  color  was  due  to  the  choroidal  pigment, 
for  dilute  sulphuric  acid  easily  dissolved  the  pigment  of  the  blood,  and  he 
made  similar  observtions  when  he  treated  sections  of  cataracta  nigra  with 
dilute  sulphuric  acid.  H.  Meyer  stated  that  he  believed  there  were  two 
forms  of  cataracta  nigra,  one  due  to  the  taking  up  of  the  pigment  of  the 
blood,  the  other  diu'  to  the  general  sclerosis. 

Vitreous  and  .[(jueinis.  For  reasons  e.\])lained  on  pages  53  and  54, 
analysis  of  the  vitreous  and  aqueous  assume  great  importance,  especially  so 
owing  to  tlieir  relation  to  the  pathological  conditions  of  the  lens.  It  is  ;. 
matter  of  regret  that  we  |)ossess  but  few  analyses  of  sufficient  accuracy. 
The  investigati(ms  of  Calm  (1.  c.,  j).  U)  have  settled  this  question  beyond 
a  doubt.  'I'he  humor  aqueous  has  a  somewhat  strong  alkaline  reaction,  and 
has  a  specific  gravity  of  1.009.  It  does  imt  contain  any  mucin,  but  a  globu- 
lin and  serum  albumen.  The  former  simulates  blood  serum  as  to  the  point 
at  which  it  coagulates.  'I'he  aqueous  has  this  qualitative  difference,  "that 
in  cooking  the  faintly  acid  solution,  the  all)umen  becomes  slightly  flaky 
and  is  precipitated,  leaving  a  clear  fluid:  whereas,  the  vitreous  always  re- 
main cloudv,  and  only  gives  a  clear  filtrate  witli  great  difficulty,  a  condi- 


33  Note  sur  la  cataraote  noire— Journal  de  :Med.  de  Bordeaux,  Bd.  IX.  p.  357. 
33a  Extraction  de  Cataraote  Noire.     Society  d  Opth.  d  Paris,  April.  1893. 


tioii  uliicli  Loll  mover  cnipliasiyA'd  and  whieli  Dcutsoliinan  misinterpreted, 
supposing  this  to  be  due  to  larger  quantity  of  albumen.  All  quantitative 
estimates  coincide.  The  average  of  six  estimates  showed  the  vitreous  to 
contain  0.0T38  pel-  cent,  of  albumen;  the  aqueous.  0.081  ])er  cent.:  hence,  a 
somewhat  greater  amount.  An  analysis  made  with  a  larger  quantity  of 
vitreous  (280  cc.)  showed  the  albumen  equal  to  0.0907  per  cent.  Lohmeyer 
found  it  to  be  0.053;  Deutschman.  O.l-^—O.li;]  per  cent.  The  following 
is  Cahn's  complete  analysis: 


Humor 

Humor 

Vitreous. 

Aqueous. 

Albumen, 

0.074 

0.082 

Remaining  Organic  Substances, 

0.071 

0.148 

Ashes 

0.971 

0.993 

Water 

98.884 

98.777 

INORGANIC  SUBSTANCES 

K„SO„     .         .         .         . 

3.74 

6.99 

Kcl,     .         .         .         . 

5.57 

2.92 

Na  cl,       . 

74.43 

78.11 

PO,H  Na„   . 

1.82 

1.99 

{FO^)^Ca„       . 

0.44 

0.62 

(POjjMgj, 

0.22 

0.40 

Na^Co, 

12.67 

8.72 

"According  to  this  the  watery  fluids  of  the  eye  are  very  similar  to  the 
cerebro-spinal  fluid,  and  the  transudates  which  are  weakest  in  albumen." 

The  material  from  which  these  analyses  were  made  was  taken  from 
animals.  In  older  analyses  made  by  Berzelius  and  Kletzinsky,  the  aqueous 
used  was  taken  from  human  eyes,  but  none  has  been  made  from  the  vitre- 
ous. One  should  judge,  that  since  the  index  of  refraction  of  both  fluids  is 
the  .same  under  normal  conditious,  any  abnormal  addition  leading  to  a 
changed  constitution  of  the  one  or  the  other  of  the  two  fluids  ought  to  bo 
demonstratable. 

Fleischer^-*  fixed  the  indices  of  refraction  by  means  of  Abbe's  refracto- 
meter.  The  value  for  distilled  water  (Line  1),  18  ])or  cent.)  being  1.3340, 
he  found  that  of  the  luiueous  equal  to  1.3373,  ami  of  the  vitreous  equal  to 
1.3369;  hence,  somewhat  less. 

Notwithstandins  the  difficulty  of  uialvin.s  estimates  witli  Abbe's  Refracto- 
iMCter  of  the  sinnll  (iiiMiil  ii  ii's  ot  .-Miiieoiis  or  vitreou.-;  wliicli  can  lie  ohraiued 
from  man,  wc  can  nevcrtliel(>ss  deterniinc  to  a  des-ree  the  index  of  refraction 
(tf  the  fluids,  and  ixn'm  comparatively  accuratt>  knowledge,  as  to  whether  the 
fluids  are  normal  in  their  constitution,  or  Avhether  they  contain  abnormal  sub- 
stances. Cor  (  vjinii'lc:  'Che  index  (-1  refraction  of  a  three-(iuarfcr  per  ceiil.  .Na. 
(11  solution,  ].3;i50;  Avliereas  that  of  water  e<iuals  l.;!;UO.    (Line  D.   IS  de.urees 


34  None  Bestimmnngen  <lei 
siiijen  Medien  dos  Auges  Inanj 


Breehungs  expo 
.    Dissert.  1S72. 


dcr  Durcbsichtigen  Fins- 


7' 
<\)  KiiiS  Jilhuiiit'ii.  <>.  IV.  i-t-r  criit.  ill  ;i  tlirf<'-(Hi;ii-t.T  per  cciii.  Xii.  CI  solution 
oiiiimI.-:  I..".: !<;.".;  (  u--  ."iiniiiicii.  (i.ir.r.  per  cent.  ('(|ii;iis  i.:;:".f;s:  (i.:;:;  per  cfin..  i.."!:;T(t 
O..")  |»«M-  cent..  1.:;:!7:t.  »>!<•.  If  llic  .nitrrior  cli.-iinlx'r  of  ;i  iionii.-il  cy.-  is  piiiiciuiM-d. 
a  fluid  will  be  (>i)1;iiiif(l  siiowiiii;  .-in  index  oT  rcli-.-iction  (MpiMl  to  1. .■;:;<;:.'.  If  the 
.•interior  cliMiulifr  is  punctured  :i^:iiii.  ten  niimiles  l:iter  it  will  lie  found  1.;1389. 
From  c.rjK'riinnils  iiniilc  nii  (niiiiiiils.  it  is  a  ircll  hniiirn  Ijiiil,  that  irith  each  siiccess- 
irc  iHUiitini .  ihi  iilhiniiiiKnis  /mrtidii  uf  llir  uiiiiiitiis  iiicrrd.sfs.  'I'lu-  vitreous  of  an 
intensely  icteric  p.-itieiit.  t.iken  hut  ;i  few  hours  after  death,  liad  an  index  of  re- 
fraction eipial  to  l.:i.S71>.  whereas,  on  hoilinjr.  it  showed  Imt  a  alight  opalescence. 

If  \\r  will  now  hold  litsi  lo  tlic  j'iict  that  hot h  aijiirous  and  vitreous  are 
poof  ill  alhtiiiu'ii.  and  that  the  anioiint  of  organic  as  well  as  inorganic  con- 
stituents scarcely  dilfer  from  each  other:  hence,  any  addition  of  substanct^s 
which  arc  normally  jjrescnt.  or  any  other  substances  whieli  do  not  occur  in 
tliem  under  iiornial  circinnstances.  will  lead  to  the  following  important 
conclusion  concern ing  the  nutrition  (d'  the  lens:  In  (jofiprnl  am/  inrirase  or 
ahuoriiHil  coitlcnls  in  l/ir  rilmins,  he  Ihnj  nrt/nnir  or  inorf/anic.  irlll  cause 
abnornidl  nnlrilirr  condillons  in  the  lens,  and  liirr  rondifions  occurring  in  the 
mpienvs  arc  flir  rrsull  of  an  inlrrferenri'  willi  the  proper  inlerchange  of  fluids 
in  the  Jens. 

Lohmeyer  •'•'  succeeded  in  demonstrating  the  presence  of  sugar  in  vit- 
reous, taken  from  two  human  l)eings  who  had  died  of  diabetes.  The  acid 
reacti(m  of  the  fluid  media  (hictic  acid)  of  the  eye,  which  he  claimed  he 
had  found,  and  which  he  also  claimed  passed  through  the  lens,  Leber  ^^ 
Avas  not  able  to  find  in  the  aqueous  taken  up  with  a  pipette  from  the  con- 
junctiva during  a  cataract  extraction  done  on  a  diabetic  patient.  Hence^ 
Leber  assumed  that  the  acid  reaction  which  Lohuu'ver  obtained,  was  due 
to  post  mortem  change.  Deutschman  ^^  proved  the  presence  of  sugar  in 
the  aqueous  and  vitreous  of  the  corpse  of  a  diabetic,  which  did  not  contain 
a  cataract,  and  whose  lens  did  not  contain  sugar.  The  aqueous  was  highly 
alkaline,  and  contained  O.o  per  cent,  the  vitreous  0.3G  per  cent  of  sugar. 

We  know  as  yet  absolutely  iu)thing  concerning  a  change  or  increase 
in  the  amount  of  albnnien  in  tlu'  vitreous  in  cases  of  senile  cataract. 

The  first  analysis  i^'lative  to  the  amonnt  of  albunu'ii  in  the  a((Ueous, 
in  cases  of  senile  cataract,  are  to  lie  found  in  h'dward  Yager's  work.  **Ubor 
die  Einstellung  dcs  dio|)tr.  Aj)|)aratn>.  eat."  (|).  1  l"^)  and  were  made  by 
Kletzinsky.     The  aqueous  was  taken  from  the  living  eye  by  puncture  of 


35  Keitra.U'  /ur  Ilistoloiiie  und  .Vetioloiiie  der  erworl)eiieii  Linseiistaare.  Zeit- 
sohrift.  f.  rat  Medicin  X.  I\.  Hd.  X'.  j..  !>!».  1S.-.4. 

36TTber  die  Erkranliun-  des  Au.iics  Itei  der  I>i:il)etes  Mellitus  Arch,  fur  Opth., 
Bd.  XXI.  .3. 

3VZur  Refreneration  des  Iloiuor  Aqueous.     Arch.  f.  Optlial..  Bd.  26.  p.  1)9. 


72 

the  cornea.  Xolwitlislaiuling  the  slipht  (juantity  wliieh  he  could  ohtain 
(0.2 — O.o  gr.),  Kletzinsky  estimated  tlie  amount  of  albumen  in  a  normal 
eve  to  be  0.0456  per  cent.,  and  that  of  three  cataractons  eyes  to  l)e  0.3G18 
0.0764  and  0.0899  per  cent.  Hence,  the  cataraclons  eyes  showed  a  great 
increase  of  albumen  over  that  fonnd  in  the  normal  eye.  Leber  (1.  c.  p.  301) 
fonnd  a  very  considerable  increase  of  the  albumen  (on  heating  a  thick  pre- 
cipitate occurred),  together  with  a  1  pro  mille  of  sugar,  in  a  patient  who 
had  diabetic  cataract,  removed  two  and  one-half  hours  after  death.  This 
observation  incited  Deutschman  to  examine  the  aqueous  in  senile  cataracts 
for  albumen.  He  found  during  the  process  of  ripening  of  senile  cataract  a 
greater  amount  of  al])unien  in  the  aqueous  than  under  normal  conditions; 
hence,  he  coincided  with  the  Yager-Kletzinsky  statement.  In  a  case  of 
acute  nephritis,  with  exceptionally  excessive  albuminuria,  the  lens  being 
transparent,  no  increase  of  albumen  could  be  found  in  the  eye.  From  this 
together  with  several  other  investigations.  Deutschman  concluded  that 
tlie  iiicn'ttsc  of  alhuiiien  ii-JiicJt  is  found  in  the  aqiieoii.s  iii  rases  of  cataract,  is 
derived  from  the  tens,  tint  lliat  tlic  cataract  i snot  due  to  an  inceased  amount  of 
attmnien  in  the  Icumor  aqueous. 

Aside  from  the  fact  whether  the  tests  made  by  Kletzinsky,  with  such 
small  quantities,  and  the  so-called  optical  tests  of  Deutschman,  are  of  suf- 
ficient accuracy  to  give  definite  results,  which  could  he  of  service  in  de- 
termining this  important  question  as  to  the  causes  of  cataract,  they  never- 
theless coincide  fully  with  those  with  which  we  are  acquainted,  concerning 
the  direction  of  the  nutritive  stream  in  the  lens.  Hence,  we  can  understand 
the  reason  for  the  constant  presence  of  a  greater  amount  of  albunum  in  the 
aqueous,  in  cases  of  advanced  senile  cataract,  which  must  have  been  derived 
from  the  lens,  and  passed  out  by  diffusion. 

One  could  account  for  the  presence  of  sugar  in  the  lens  and  a([ueou5 
by  a  similar  mode  of  reasoning. 


PART   II. 

'I^JIK   l'.\'ni()I.(»(ilC.\l.   LKXS  SVSTK.M. 

CHAPTER   I. 

THP]  PATH0L0C4Y  OF  THE  ZONULA  OF  ZTNX. 

Even  at  the  present  day  but  little  is  known  concerning  the  patholog- 
ical anatomy  of  the  zonula  of  zinii.  on  the  noiiual  integrity  and  develop- 
ment of  which  the  lens  is  so  prominently  dependent,  not  only  for  its  proper 
position,  but  also  for  its  ability  to  properly  perform  its  function  during  the 
act  of  accommodation.  It  might  also  be  com])ared  to  the  hairspring  of  a 
watch. 

Becker  1  states  that  at  times  there  is  such  a  complete  (ifropln/  of  the 
zonula  fibres  that  one  can  not  recognize  a  trace  of  its  fibrous  construction. 
This  may  lead  to  a  spontaneous  detachment  of  the  lens  in  its  capsule,  par- 
tial or  complete.  This  condition  in  all  probability  agrees  with  one  de- 
scribed by  Wedl  and  Bock  -  as  senescence  of  the  zomda.  They  describe  the 
zonula  fibres  as  taut,  ap])arently  closely  packed  together,  and  easily  torn 
from  their  attachment  on  the  application  of  a  certain  degree  of  force.  When 
detached  they  are  tense  and  friable.  This  condition  is  taken  advantage  of 
when  the  lens  is  extracted  in  its  capsule  (Pagenstechers  operation). 

Again,  Becker  states  ^  that  it  is  not  at  all  uncommon  in  cases  of  disor- 
ganized eyes,  more  jjarticularly  in  cases  where  cataract  has  developed,  to 
find  a  marked  inm-dse  of  the  zonula  fibres.  These,  he  states,  may  be  ob- 
served in  the  fresh  as  well  as  in  hardened  specimens,  as  chmdi/,  thickened 
fibres,  adherent  to  the  ciliary  body  and  the  capsule  of  the  lens.  Wedl  and 
Bock  (p.  T< )  state  that  in  eataractous  eyes  the  connective  tissue  corpuscles. 
which  are  normally  ])resent  at  the  time,  are  greatly  increased,  and  lead  to 
a  cloudiness  of  the  zonula.  In  the  great  majority  ol;'  disorganized  eyes, 
such  as  phthisical  1)ulhi.  those  which  have  snlVered  I'l'oin  iridocyclitic  pro- 
cesses, the  infiammatory  products  lill  up  the  posterior  chamher.  and  the 
zonula  fibres  likewise  become  iinmersed  in  the  exudate,  ivatei'  on  these 
inflammatory  products  organize;  tense  bands  develop,  and  as  they  undergo 
cicatrical  contraction  lead  to  dislocation  of  the  lens,  even  to  detachment  of 


irathologie  and  Therapie.    Graefo  S.-ieinisch  Vol.  p.  KH.  No.  11. 

2  Pathologisclio  Anatomie  des  Aujres.    Wieii.  ISSO.  p.  177. 

3  Pathologie  and  Tlierapie,  p.  102. 


74 

the  entire  cilinrv  body.  No  doiibt  ;it  iiiiics  iliesc  Imiuls  have  l)een  inistakeu 
for  thickened  zonular  fibres.  Move  as  the  rcsidt  of  clinical  observation  than 
of  anatomical  examination  it  has  been  obsci-ved.  that  in  cases  of  si/nrhifiis 
corporis  rihri,  the  zoniihn-  fibres  are  also  alfected.  loose  their  consistence, 
and  are  totally  dissolved.  This  is  evidenced  in  c;ises  of  s|)ontaneons  lux- 
ation of  the  lens,  where  at  the  bejiinninu-  there  is  iiidodonesis,  with  the 
leiis  still  propei'ly  centered.  Latei'  on.  due  to  the  continuous  niovenu'nts  of 
the  eyeball,  and  conse(|uenl  oscillation  of  the  lens,  as  a  natural  ivsult  of  the 
continuous  tension,  the  zonula  tibi-es  finally  rn|)ture.  Owin.ii-  to  the  inti- 
mate genetic  relation  existing  between  the  zonula  fibres  and  the  vitreous 
(as  pointed  out  on  i)age  27),  one  might  assume  that  the  sauu'  causative 
agent  which  leads  to  the  pathological  destruction  of  the  vitreous,  or  its 
chemical  decomposition,  acts  exactly  in  the  same  manner  on  the  zonular 
fibres. 

Solution  of  conliniiili/  can  always  occur  as  the  I't'sult  of  the  application 
of  mechanical  foi'ce.  hut  tjie  manner  of  its  j)roduction  may  be  brought 
about  in  vai'ious  ways.  Two  causes  have  already  been  cited  above.  Trac- 
tion which  the  shiinking  capsular  cataj'act  exerts  on  the  zonula,  or  the 
dragging  which  it  e.\pei'iem-es  where  the  acpieous  is  suddenly  evacuated, 
due  to  a  corneal  ruptui'c.  the  result,  either  of  a  trauma  or  operative  pro- 
ceedure.  may  produce  this  disaster,  the  lens  moving  anteriorly  a  distance 
equal  to  its  axial  dianu'ter.  Mcu'e  fre(pu'ntly,  however,  the  zonula  does  noi 
j-upture  at  oiu'c.  but  the  lens  I'cmains  adherent  at  the  point  where  the  |)er- 
foration  occurred;  ami  it  is  only  after  the  anterior  chambt'r  is  re-estab- 
lished, and  the  aqueous  accumulated,  that  the  zcuiula  teai's.  I']ctatic  ]>ro- 
cesses.  hydi'opt  haliiius.  cornea,  globosa.  staphyloma  iutei-calare:  in  fact,  all 
forms  of  staphylomata  of  the  anterior  segnicnt  of  the  globe,  lead  to  p;irtial 
or  entire  ru|)ture  of  the  zonula,  due  to  the  continually  increasing  tension 
exerted  on  the  zonula  fibres  by  the  gradual  distension  of  the  anterior  seg- 
ment of  the  globe.  Whci-e  the  eye  is  struck  by  a  blunt  foi'ce  and  suddeidy 
flattened  out.  and  a.-sunu's  ag;iin  its  normal  shape,  mit  infre(puMit  ly  the 
lens  is  found  luxated,  and  this  is  only  possible  where  there  is  at  least  a  par- 
tial teai'  of  the  zonula.  The  >ame  re.-ult  is  noted  of  a  contusion,  and  as  is 
well  known:  this  latter  coiuliti(ni  most  fre<pu'ntly  occurs  in  the  ri'gion  of 
the  ciliary  body.  Lastly,  the  zonida  may  be  toi'ii  by  a  foi-eign  body  pt'ue- 
trating  it  alone,  or  at  the  same  time  involving  neighborly  ,-tructures  as  cil- 
iary body  and  lens,  without  necessarily  leading  to  loss  of  either  a(picous  or 
vitreous. 

Ccrlaiii  oiKiloiiilcdl  uiKinKilirs  nf  llir  ri/clxill  are  a>socialed  with 
aiionialicx  in  llir  forninlion  of  Ilir  -.oniilo.  In  all  the  varielie>  of  colobomata 
(coloboma  of  ii'is,  ciliary  body,  choroid,  and   I'ctina),  supposed  to  be  due  to 


75 
laic  closim'  of  the  ot-iilar  lissiwc.  otic  IIiuU.  a>  one  would  iialiirally  I'xpect 
to  find,  a  failiiiv  of  perfect  dcvclo|)iiiciil  of  the  zonula  fibres,  especially 
along  the  line  wlici'c  the  closure  look  place,  and  in  these  [)laees  the  lens 
follows  the  tension  from  aho\e.  'rrcacliei-  Collins  (see  page  2^))  explains 
cases  of  colol)onia  lentis  as  due  to  want  of  proper  adhesion  between  the 
ciliary  portion  of  ihe  retina  and  capsnie  of  the  lens  at  a  very  early  period 
of  (1evelo])nient.  heforc  the  expansion  of  the  eyeball  begins.  Mctopia  lentis. 
he  e.\|)lains  in  a  siniilai-  manner,  as  due  to  a  lac-k  of  development  of  the 
zonula  iibres.  lie  further  states:  "If,  a.s  a  result  of  persistence  of  the  hya- 
loid artery,  the  tibro  vascular  sheath  around  the  lens  persists  and  becomes 
thickened,  it  may  occui-  that  the  lens  be  forced  forwaid  between  iris  and 
ciliary  processes,  without  leading  to  adhesions  laterally:  as  a  result,  there 
will  be  no  traction  and  no  -jiniilar  /ihrt's.  simply  an  epithelial  deposit  on  the 
posterior  capsule,  and  the  lens  then  assumes  an  almost  globular  form." 

CHAPTEK   11. 

THE  P.\THOL()(;i('AL  CHANGES  IX  TIIF.  LHXS. 
LENTirULAI?  CATAlJAl  T. 

"During  the  ])resent  century  the  pathological  anatomy  of  the  lens  has 
been  the  subject  of  a  great  many,  and  in  part  very  accurate,  publications. 
Hundreds  of  years  ago,  owing  to  the  extreme  importance  which  opacities 
of  tlie  lens  bear  to  those  so  aflflicted.  the  operations  for  cataract  awakened 
an  interest  which  was  not  alone  confined  to  the  jihysician.  Hence,  it  is 
easy  to  umlerstand  why  every  effort  has  been  made  to  clear  u)).  by  accurate 
anatomical  investigation,  the  cause  of  cataract."  It  is  only  since  the  early 
part  of  the  last  century  that  we  know  that  grey  cataract  has  its  seat  in  the 
len.s,  and  it  is  only  during  the  past  fifty  years  that  we  know  anything  at  all 
concerning  its  histological  structure.  The  past  twenty-five  years  have  been 
ripe  with  a  succession  of  ])ublications.  nu)re  especially  the  past  fifteen  years, 
owing  to  the  rcHnement  in  tlu'  techni(pie  in  the  preparation  of  specimens 
and  in  our  possession  of  l)etter  nn'croscopes:  ami  as  a  result,  our  knowledge 
of  the  pathology  of  the  lens  has  gradually  been  placed  on  a  solid  founda- 
tion. And  at  this  point  it  seems  no  more  than  just  and  ])roper  to  again 
draw  attention  to  the  great  efforts  made  in  this  direction  by  Otto  liecker. 
whose  masterly  descriptions  are  the  basis  of  the  following: 

"The  impetus  to  study  the  pathological  anatotny  of  the  lens  was  given 
by  :\lalgaigne.  and  corresponds  with  the  time  when  histology  in  geiu'i-al 
was  undergoing  i'evi>ion  by  Sehwan.  Malgaigne  contended  (l<S4t)).  ami 
based  his  contentions  on  post  mortem  examinations,  that  there  was  no  such 


76 

Thing  as  a  capsular  cataract :  that  is,  that  thei-e  existed  no  true  cloudiness 
of  the  capsule  per  ><e.  This  statonieut  aroused  extraordinary  interest,  and 
thereupon  Cunior.  the  puhlisher  of  'The  Annales  de  Oculistic'  took  occa- 
sion to  olTcr  a  prize  for  the  best  essay  on  this  subject.  This  was  very  learn- 
edly and  scientifically  answered  l)y  two  young  German  physicians,  Iloring 
and  Strieker.  Especially  in  the  woik  of  Iloring  do  we  find  the  correct 
ideas  regarding  the  fonnation  of  the  lens,  and  in  this  he  was  far  in  ad- 
vance of  his  contemporaries.  Both  declared  against  Malgaigne;  but  it  ap- 
pears that  both  sides  misunderstood  each  other.  It  is  not  necessary  at  the 
present  day  to  draw  attention  to  the  fact  that  at  tlie  time  Malgaigne  was 
making  his  investigations,  a  large  pi-oportiou  of  the  cases  of  cataract  de- 
pendent on  cloudiness  of  the  cortex,  were  considered  as  capsular  cataracts. 
In  looking  over  the  clinical  histories  of  that  time,  one  frequently  finds  the 
statement  made,  that  after  reclination  the  capsular  cataract  which  re- 
mained in  the  pupil  was  gradually  absorbed.  As  that  which  we  today  desig- 
nate as  capsular  cataract  is  not  aifected  by  the  aqueous  humor,  and  as  one 
does  not  wish  to  doubt  the  correctness  of  their  observations,  the  cloudiness 
which  remained  in  the  pupillary  area  must  have  been  remains  of  cortical 
substance.  Therefore,  Malgaigne  was  correct  when  he  contended  that  that, 
which  at  that  time  was  called  capsular  cataract,  was  situated  in  the  cortical 
•  substance  and  not  in  the  capsule.'" 

SENILE  CATARACT. 

It  seems  advisable,  in  taking  up  the  study  of  the  pathology  of  the 
lens,  to  begin  with  the  study  of  senile  cataract.  Because  of  its  frequency 
we  have  better  opportunity  for  making  clinical  obseiTations,  which  can  be 
verified  by  anatomical  examination.  Senile  cataract  also  offers  us  the  op- 
portunity of  studying  all  those  changes  which  are  characteristic  of  other 
varieties  of  cataract,  which  manifest  themselves  here  in  varying  degrees  of 
intensity.  The  ])athological  changes  may  be  considoi'cd  under  two  general 
groups.  First,  those  of  (tei/eneration  or  retrogressive  nietnniorpltosis  and  or 
new  celtalar  formation:  secoiul,  those  of  rec/eneration.  the  so-called  atrophic 
cellular  hyperplasias. 

l^ecker  states:  ^  'Tu  senile  cataract  one  must  assume  that  where  the 
sclerosing  process  does  not  proceed  in  an  absolutely  regular  and  continuous 
manner,  so  as  finally  to  lead  to  the  formation  of  a  caianicla  iiiijra.  the  com- 
]jlete  saturation  with  nutritive  Huid  is  interfered  with,  and  thus  leails  to  a 
loosening  up  of  the  lamella  immediately  a<ljacent  1..  the  nucleus.  Besides 
this  there  is  a  meehanieal  c.-uise  lor  this  loosening  u|»  of  the  lamellae.   Owing 


1  I'Mtliolo^iie  iiiid  Tlieriii>ie.  Section  80,  p.  182. 


77 
to  the  compiict  condition,  and  hence  icduci'd  volume  of  ihe  n\icleus.  there 
necessarily  follows  a  certain  anioiini  of  traction  on  the  more  peripheral 
portictns  of  the  lens.  Those  jiortioiis  of  the  cortex  in  the  region  of  the  an- 
terior and  ))osleii()r  ])ole  and  tlie  cai)suie.  since  they  are  not  fixed  hy  the 
zonula,  can  give  to  this  traction.  I'.ut  in  the  e(|uatonal  region  tlie  condi- 
tions are  difl'oreiit.  To  heuin  with,  here  the  connection  between  the  la- 
melhie  is  less  intimate,  since  it  is  here  that  the  youngest  lens  fibres  aro 
found.  1'hen  again  the  zonula  tixos  the  cap.-iile.  and  prevents  the  equa- 
torial ])()rtio)i  of  the  lens  from  Ix-coniing  fnrthci-  removed  from  the  ciliary 
body,  and  ap]ir.)aching  the  axis  of  the  eye.  Hence,  it  can  not  be  such  a 
matter  of  surprise  tliat  in  senile  cataract,  the  equatorial  portion  of  the  lens 
is  the  first  to  sutler  a  loosening  up  and  separation  of  its  cortical  lamellae 
{geronfo.von  lenli!<).  and  that  this  is  subsequently  followed  by  a  true  cloudi- 
ness of  the  lens  fibres,  and  a  molecular  disintegration  (cataract  formation). 
Foerster^  appears  to  have  been  uncler  the  impression  that  "the  firsi 
indication  of  a  cataj-act  ohra!/.'<  makes  its  first  appearance  around  the  nu- 
cleus of  Ihe  lens,  as  a  result  of  interference  with  the  gradual  sclerosis,"  and 
states  "that  a  very  delicate  but  .<harply  defined  line  of  demarcation  can  be 
observed  along  the  e(iuatorial  line  of  the  nucleus,  which  at  times  may  even 
be  observed  with  the  naked  eye  or  use  of  a  loup  after  tlie  lens  has  been  ex- 
tracted." 

Since  tlie  introduction  of  the  refracting  opthalmoscope  for  diagnostic 
purposes  by  Hirschberg^  and  Magnus/  it  has  been  successfully  demon- 
strated that  it  is  possible  to  study  the  development  of  cataract  from  its  very 
incipiency.  This  lias  not  only  given  us  the  means  for  making  an  earl} 
diagnosis,  but  has  assisted  us  in  formulating  a  theory  as  to  the  cause  of  its 
development.  By  starting  mth  a  -|-  6  D  lens,  and  gradually  increasing  its 
strength,  one  can  successfully  focus  the  entire  thickness  of  the  crystalline 
lens,  and  by  this  means  note  the  minutest  changes.  In  this  manner  Magnus 
conducted  166  examinations,  and  was  enabled  to  observe  the  very  first  deli- 
cate changes  which  lead  up  to  the  development  of  senile  cataract.  Gener- 
ally speaking,  he  observed  two  types  of  development.  In  92.77  per  cent,  of 
the  cases  wl'ich  he  examined,  the  first  signs  developed  along  the  equatorial 
line  of  the  lens:  that  is,  in  a  zone  running  parallel  to  the  anterior  and  pos- 
terior surfaces.  Amnion's  so-called  (icmnloxon  lerilis.  The  second  type  in 
which  the  changes  are  rapidly  developed,  form  about  7.23  per  cent  of  the 


2  Becker's  Anatomie.  p.  52. 

SCentralblatt   fnr  Trnkt   Aus.'nl.eilkuntlo.   ISSC.   ]..   :m;  1888.   p.  360;   1889, 

p.  330. 

4  Pathologisch   Anatomisohe   Studien   ubor   die   Anfance   des   Altersstaares. 

Graefe's  Arch.,  Vol.  XXXY,  B.  3.  18S9. 


78 

cases.  ;iii(l  disclose  the  (irst  sjo'iis  alon.u'  llic  r(/ii(il(ir  of  llir  iiiiclnis  of  the  Ions. 
Tims  Mii,i:ii  lis  was  eiial)le(l  lo  (litt'ereiuiale  live  xarii'ties  i.f  iii1ers|>aces.a>  iiuui- 
ifostatioiis  (if  (levelopin.u-  cataract  at  a  time  wlieii  the  lens  was  apparently  per- 
fectlynoniial.  ••/•'/';•>■/;  pear-shaped  iiitei>paees  aiTaiijicd  concentrically  around 
the  equator.  JSerotid,  lar<rc  spindle-shaped  interspaces,  in  all  probability 
outoTowtbs  of  the  pear-shaped.  Third,  small  sj)indle-sliaped  interspaces 
which  at  an  early  sta<>e  are  found  tlirou<ihout  the  lens.  Fourth,  small  and 
large  globules  dispersed  through  all  the  lamellae.  Fiflli.  line  dust-like 
opacities  which  occur  at  an  early  stage  throughout  the  cloudy  zoiu'.  In  the 
beginning  the  interspaces  appear  perfectly  transparent,  like  capillary  tubes 
filled  with  clear  fluid:  later  on,  they  appear  as  though  covered  by  a  delicate 
veil;  then  the  cloudiness  becomes  more  saturated  and  the  contours  more 
sharply  defined,  until  finally  they  coalesce  with  neighboring  interspaces. 
These  cloudy  interspaces  extend  either  uniformly  toward  the  centre  or  they 
sit  as  radii  on  the  erpiator."  .\s  the  cataractous  process  goes  on,  they 
coalesce,  forming  band-like  processes,  which  surround  the  equator  of  the 
lens,  or  they  extend  inward  toward  the  centre  of  the  axis  of  the  lens  as 
prismatic  sectors.  As  has  been  stated  above,  Becker  looked  upon  these  in- 
terspaces as  the  result  of  interference  with  the  otherwise  regularly  progress- 
ing sclerosis  of  the  lens,  and  as  a  result  a  les*!  intimate  and  regular  con- 
nection between  the  individual  lamellae;  the  first  demonstratable  sign  of 
an  interference  wdth  the  formation  of  a  nucleus.  In  these  interspaces  the 
tissue  fluid  stagnates,  undergoes  chemical  changes  and  leads  to  degenera- 
tive processes  in  the  lens  fibres  themselves.  "The  originally  normal  fluid 
which  has  an  index  of  refraction  equal  to  that  of  the  formative  elements  of 
the  lens,  after  a  time  stagnates  in  these  spaces,  and  thus  leads  to  abnormal 
processes  of  diffusion  between  itself  and  the  contents  of  the  lens  fibres.  As 
a  result,  it  withdraws  from  the  lens  fibres  a  part  of  their  c-ontents  and  give 
up  a  part  of  its  own.  'J'his  leads  to  disturbance  of  nutrition,  which  in  turu 
leads  to  an  alteration  in  the  chemical  constitution  of  the  tissue  fluid  and  the 
lens  fibres,  and  these  changes  are  numifested  by  a  change  in  the  index  of 
refraction  of  both  the  stagnant  fluid  and  the  lens  fibres."'' 

Pi'iestly  Smith,  in  a  pai)er  read  before  the  Opthal  Society."  expressed 
a  similar  opinion,  stating:  "Vln  the  tabulated  j-esults  tlu'  relation  of  senility 
to  the  de\clnpiiieiit  of  cataract  comes  out  clearly.  Leusi's  which  showt'd  any 
opacity  were  distinguished  from  others  and  wen-  found  when  tabulated  to 
he,  on  the  average,  smaller  than  transparent  lenses  of  the  sanu'  age.  .\s 
this  dift'erence  was  present   even  when   the  opacities  were  very  slight,   it 


5  Becker  At.  P..  \).  58. 

6  Med.  Times  and  (Jazett 


79 
sct'MH'd  likely  tliat  m  jxTiod  of  (liiiiiiiislicd  rate  of  Litowlii  preceded  tli<' 
foi'matioii  of  the  opacities  of  senile  entaraet  and  wci-e  in  most  cases  limited 
to  the  ('((uatorial  zone,  wliere  the  ca|)sule  and  the  coitical  layers  of  the  Utis 
were  suhjected  to  the  traction  of  the  sus|)ensory  ligament."  Thns  he  snp- 
])orts  Becker's  conclusions  ([noted  ahove. 

By  the  recognition  of  this  heretofoi-e  overlooked  factor,  nanicly.  that 
ihose  lenses  in  which  senile  ((ttiirdcl  lias  hcf/iin  to  ilrrchip  liarr  <i  Irsscr  r<iliiiiir 
lh(in  lenses  of  th^  same  (if/c  ichicli  arc  free  fraiii  opdcilics.  we  cei-tninlv  have 
advanced  greatly  in  our  understanding  of  the  genesis  of  senile  cataract. 
Hence  the  splitting  and  iissuring  of  the  conical  siil)stance  will  he  followed 
])y  a  degree  of  shrinkage,  greater  than  the  physiological  retrogressive  pro- 
cess. 

'Vhv  sclerosing  process  proceeds  elitl'erently  in  dilt'erent  indivitluals.  Jt 
may  go  on  uninterruptedly  to  exti-eme  old  age.  Becker  states  that  he  ob- 
served a  yellow  nucleus  and  clear  cortical  substance  with  vision  equal  to 
()-9  in  an  individual  ninety-four  years  of  age.  In  other  cases  tlie  lens  is 
changed  into  a  dry.  hard  brown  mass  up  to  the  very  ca|)sule.  which,  with- 
out any  cloudiness  appearing  in  the  pupillary  area,  absoi-hs  so  much  light 
as  to  materially  impair  vision.  (Cataracta  nigra.)  Again,  the  process  is 
arrested  when  it  reaches  certain  peri])heric  lamellae,  the  nucleus  separates 
from  the  cortex,  and  the  latter  disintegrates,  the  products  of  which  when 
they  have  rwached  their  greatest  degree,  absorb  so  n\uch  light  that  simply 
(piantitative  perception  remains.  {Catararta  senilis  imiliini).  The  sclerosed 
nucleus  suffers  no  further  change  except  in  cases  where  the  condition  re- 
mains for  a  long  time;  the  outer  lamellae  may  then  become  softened  and 
melt  away.  As  the  cataractous  process  goes  on,  the  volume  of  the  lens  in- 
creases, and  the  more  rapidly,  the  more  cloudiness  develops.  After  the 
cortical  cloudiness  is  complete  and  attains  its  greatest  volume,  the  volume 
again  hecomes  lessened  and  the  cataractous  mass  begins  to  thicken.  The 
taking  up  is  followed  by  the  giving  off,  of  water.  In  tlu'  course  of  this  re- 
duction, a  stage  is  n^ached  in  which  the  volume  of  the  lens  ecpials  that  of 
a  senile  lens.  (.\rlt"s  "Stage  of  Hij)eness.")  'I'his  is  followed  by  the  stage 
of  over-ripeness  characterized  by  a  reduction  in  the  volume  of  the  lens,  and 
the  appearance  of  whitish,  ])unctate  and  striated  opaque  s])ots  on  the  inner 
surface  of  the  anterior  capsule  and  hy  the  disappearance  of  the  hithert>. 
recognizable  I'adial  arrangement  of  the  lens  tihres. 

For  the  further  retrogressive  metamorphosis,  we  are  forced  to  assume 
entirely  different  changes  in  the  lens.  Hither  the  cortical  substance  be- 
comes more  and  luore  thickened,  accompanied  hy  the  fonnation  of  caji- 
sular  cataract,  or  the  cortex  gradually  hecomes  a  fluid  pasty  mass,  in  whicli 


So 

is  found  an  abundance  of  eholesterine  and  chalky  dcj)osits.  and  in  wliicli 

the  nucleus  finally  sinks  to  the  bottom  (Cataracta  Morgagni). 

On  microscopical  examination,  these  splits  and  inters'])aces  are  found 
to  be  filled  with  coagulated  albuminous  glolndes.  Innumeraljle  direct 
observations  have  settled  this  as  an  unassailable  fact,  and  this  has  been 
especially  demonstrated  in  lenses  which,  during  life,  had  shown  signs  of 
cataracin  'uuijnens.  and  have  conclusively  proven,  that  it  is  these  forma- 
tions which  are  the  cause  of  the  first  opacities  in  the  cortex  of  incipient 
cataract.  These  are  the  so-called  "Moir/tu/ni's  globules,"  and  have  long 
ago  been  observed  in  posterior  cortical  cataract.  It  must,  however,  remain 
an  undecided  question  as  to  whether  this  fiuid  coagulates  into  globules 
during  life,  or  whether  this  is  simply  the  result  of  a  cooling  ofl'  of  the  body 
after  death,  or  due  to  the  action  of  the  hardening  fluid,  or  due  to  both  the 
latter.  Due  to  the  influence  of  the  changed  fluid  in  these  interspaces,  the 
fibres  undergo  a  variety  of  changes,  all  the  various  degrees  of  which  can  be 
observed  without  any  difliculty  under  the  microsco])e,  beginning  ^nth  the 
punctate  molecular  cloudiness  of  the  fibres  u])  to  highly  refracting  drop- 
lets, from  the  irregularly  serrated  borders  of  the  fibres  up  to  the  transverse 
striations:  from  the  tumesence  to  the  gradual  transition  into  cylindrical 
tubes.  The  first  stage  of  disintegration,  the  dislocation  of  the  lamellae  one 
against  the  other,  the  breaking  down,  disintegration  and  total  destruction 
of  the  individual  fibres,  the  formation  of  albuminous  globule^,  molecular 
pasty  masses,  calcareous  granules,  fat,  eholesterine  crystals,  can  all  be  ob- 
serA'cd  under  a  low  power  of  the  microscope. 

If  a  nucleus  has  formed,  the  cataract  as  a  rule  must  develop  in  those 
portions  of  the  lens  which  are  not  yet  sclerosed.  The  older  the  individual 
at  the  time  the  cataract  begins  to  form,  the  larger,  generally  speaking,  will 
be  the  nucleus  which  is  surrounded  by  the  cataractous  ma^s;  whereas  the 
younger  the  individual  at  the  time  the  cataract  begins  to  forni,  the  easier 
will  it  be  ft)r  the  entire  lens  to  become  cataractous.  But  no  sharp  line  be- 
tween nucleus  and  cortex  can  be  drawn,  estimated  by  the  age;  it  is  an 
exceedingly  rare  occurrence  to  find  the  centre  of  a  lens  undergoing  cata- 
ractous changes  after  a  nucleus  has  once  formed.  In  those  cases  where 
the  centre  of  the  lens  is  first  attacked,  it  is  still  an  undecided  question 
whether  the  cataractous  |)rocess  had  been  preceded  by  the  formation  of  a 
nucleus,  or  whether  it  had  occurred  as  a  result  of  the  failure  of  a  nucleus 
to  properly  foi-iii. 

CATAiJA(  '1'  IX   VOI'IMIKIL  LENSES. 
The  causation   of  the  spontaiu'ous  (lcvelo].uient  of  soft   cataracts  in 
youthful  individuals  is  still  wrapped  in  llic  deepest  darkness.     Anatomical 


investigations  arc  enlirely  wanting,  and  our  knowledge  is  therefore  en- 
tirely restricted  to  the  results  of  clinical  investigation.  The  only  case  which 
Becker  was  enabled  to  examine  anatomically  was  obtained  from  a  diabetic 
patient,  a  girl  nineteen  years  of  age.  II  is  a  well-set tU'd  fjict.  tlial  a  devel- 
oping diabetic  soft  cataract  of  a  youthful  individual  differs  in  no  way  in 
its  appearance  from  any  other  soft  cataract  of  yonth.  The  lens  is  tumescent, 
shows  the  well-known  ])ciii-ly  grey,  radially-arranged  silky  opacities  wliicli 
aitl  us  in  recognizing  the  ai-rangement  of  the  lens  fibres  around  the  an- 
terior pole;  between  these  are  the  dark  striations  which  are  to  he  looked 
upon  as  the  interspaces  filled  with  the  transparent  fluid.  The  IniiDnntic 
cataract  has  exactly  the  same  appearance  when  it  occurs  in  a  youthful  in- 
dividual. Examination  of  such  traumatic  cataracts  and  the  diabetic  cata- 
ract has  shown  that  they  have  this  in  common,  that  the  interspaces  and 
splits  are  especially  pronounced  and  numerous,  between  the  lamellae  and 
the  fibres,  and  that  they  are  undoubtedly  the  cause  of  the  opacities.  It  is 
worthy  of  special  emphasis  that  the  dark  striations  between  the  silky  stria- 
tions which  seem  to  be  due  to  splits,  on  anatomical  examination  of  trau- 
matic cataracts  were  found  in  reality  to  be  due  to  splits.  It  is  further 
worthy  of  note,  that  if  one  takes  a  lens  denuded  of  its  capsule  and  exposes 
it  to  the  air  until  it  is  perfectly  dry,  it  will  split  up  similarly  into  small 
sectors.  Eobinski  '^  makes  mention  of  the  same  fact.  Hence,  in  the  de- 
velopment of  soft  cataract  of  youthful  individuals,  we  are  likewise  dealing 
with  a  splitting  up  of  the  lens,  and  in  these  cases  the-  peripheric  lamellae 
are  first  attacked,  the  more  centrally  located,  later  on.  Here  the  cloudiness 
of  the  lens,  as  it  appears  to  the  one  making  the  examination,  as  well  as 
the  impermeability  to  light  in  the  eye  so  affected,  is  caused  by  the  differ- 
ence in  the  index  of  refraction  of  the  lamellae  as  they  are  superimposed 
one  over  the  other.  Undoubtedly  the  individual  lens  fibres,  and  the 
lamellae  composed  of  these,  possess  a  greater  index  of  refraction  than  the 
fluid  which  has  accumulated  between  them.  Though  it  be  true  that  the 
fluid  which  accumulates  in  the  interspaces  in  incipient  senile  cataract  is 
simply  tissue  fluid  which  is  normally  present,  hut  in  increased  ((uantity, 
it  is  equally  true  that  in  the  soft  cataracts  of  youthful  individuals  the 
fluid  which  oeeu])ies  these  interspaces  has  fi'oiu  the  very  beginning  gained 
entrance  in  an  abnormal  way,  namely,  by  dilfusion,  from  without  into  the 
capsule  sac.  This  seems  to  be  attested  l)y  the  fact,  that  the  substance 
which  occupies  these  interspaces  has  an  index  of  i-etVaction  about  equal  to 
that  of  the  aqueous.     In  traumatic  cataracts  the  source  of  this  fluid  is 


7  Augen  Linsen  Staare  der  Menschen  nnd  der  Wirbelthiere  Ceutralblatt  f.  d. 
Med.  Wiss.,  1877,  Nos.  3  and  4. 


82 

evident.  It  enters  through  tlie  wound  in  the  eapsule.  Subsetjuently, 
streams  of  diffusion  between  the  fluid  which  has  entered  and  the  contents 
of  the  lens  fibres,  as  well  as  between  the  lens  and  the  aqueous  through  the 
capsule  will  take  part.  'J'his  liypotliesis  seems  necessary  because  at  times 
we  find  the  capsule  closes  again,  and  still  the  opacities  increase. 

Fi'om  the  very  beginning  we  have  assumed  streams  of  dift'usion  to 
explain  the  development  of  diabetic  cataract. 

Kveii  in  the  consecutive  cataracts  of  youthful  individuals,  the  appear- 
ance is  exactly  that  of  the  foregoing.  Under  such  circumstances  there  de- 
velops, even  in  veiy  advanced  old  age,  as  the  result  of  the  rapid  taking  up 
of  water,  a  cataract  with  a  soft  cortex,  and  it  appears  that  it  may  even 
.soften  u])  a  sclerosed  nucleus.  In  these  cases,  no  other  explanation  seems 
possible  than  that  the  addition  of  a  pathologically  changed  nutritive  fluid 
lias  led  to  this  splitting  up.  The  taking  up  of  water,  the  stage  of  tumesence 
in  the  soft  cataract,  just  as  in  the  senile  cataract,  is  to  be  looked  upon  as  the 
second  stage  of  the  formation  of  cataract. 

The  subsequent  changes  are  almost  identical  with  those  of  senile  cat- 
aract: oidy  that  we  find  appearing  in  the  fibres  of  youthful  individuals, 
especially  after  discission  or  a  trauma,  the  well-known  and  frequently 
described  raciiules  in  large  numl)ers.  The  wavy  contours  of  the  tumescent 
peripheric  fibres  are  very  striking.  Finally,  the  entire  lens  seems  to  take 
part  in  the  cataractous  degeneration,  there  being  no  hard  nucleus.  It 
seems  much  easier  for  calcareous  deposits  to  take  place  in  this  final  stage 
than  in  cataracts  occurring  in  old  age. 


CHAPTKll  III. 

TPIE    PATIIOIJXJJCAL    (TIAXGKS    IX    TIIH    IXTKACAPSULAR 

CELL'S. 

(JAPSULAR  CATARACT. 

A.  THE  DECENERA^riVE  CHAXGES. 

The  degenerative  processes  are  sharply  differentiated  from  the  phe- 
nomena of  physiological  retrogression  already  described.  If  oiu'  may  be 
])ermitted  to  so  express  himself,  the  latter  consists  of  an  atrophy  of  the 
nuclei  and  cells,  whereas  we  are  luM-e  dealing  with  a  metamorphosis  begin- 
ning in  the  nucleus,  then  atlVcting  the  entii-e  cell;  as  a  result  the  cells  be- 
come changed  into  a  |)ath()logical  s\d)stanee,  the  chemical  nature  of  which 
Jias  not  been  as  vet  t'ullv  detei'niiiu'd. 


83 

II.  Miill.'i-.  ill  lii>  llr>t  t'^iiv  on  tlii>  >iil)Jcct.'"  (IcscrilM-  iwo  kiii<l>  of 
deposits  oil  the  iiinci'  >iirt;i(r  of  the  jiiitcrior  capsule  He  states,  "Some 
of  these  exteiul  over  I  lie  >iirt'a(c  and  seem  in  prolilc  as  striations  which  are 
easilv  (litVcrentialed  fr.nii  \\\r  cap-nle:  tor  a  crilaiii  (li>tan(c  tliey  may  sliow 
a  reu-ular  (h^uivc  of  lhi(knc».  On  tin'  oilier  hand,  they  may  form  ))la(pies 
with  no  evident  connection  with  one  anolhci'.  I'litliei'  llicv  aiv  adhcivtii 
by  a  hroad  Hat  i)ase.  or  they  form  ^lohnlo  oi'  icnpin-likc  strnctnro.  wlnc'.i 
show  .ureal  similarity  lo  the  papillae  of  the  iiescenieti>  or  the  isolated 
"Drusen"  (warty,  hyaline  excrescences)  of  ihe  vitreous  lamellae  of  the 
choroid."  The  substance  which  forni>  tlie>e  structures  is  very  much  like 
the  capsule  itself  is  transparent,  and  refract>  the  liuht.  Ao-ain.  it  may  not 
show  >ucli  a  perfectly  i-e.uiilar.  liomo.-ieiioiis  sti-iicture.  but  show  yellowish 
li,i>hter  and  darker  spots,  even  iiranular  masses. 

This  latter  lonii  of  (iei><isit.  wliidi  .Miiller  has  (h'ScriluMl  as  Itejirini:  siuli  a 
close  sinillaiity  u>  llie  I  Museii  of  Tlie  elioroid.  Becker  states,  lie  was  enabled  to 
study  from  its  very  ineipieiiey.  The  cataract  was  preserved  five  weeks  iu  a  4'. 
per  cent,  solution  of  alet>h(»l.  the  capsule  was  stained  with  haemotoxylin.  and  a 
portion  was  then  imbedded  and  cut:  the  larger  portion  was  put  up  in  glycerine. 
The  specimen  haviiit;  u'rown  pale  in  course  of  time,  it  was  .stained  again  with 
l.aemotoxylin  and  eosin.  aii.l  tli.'U  i.ut  up  in  Canada  balsam.  This  .specimen 
.showed  long  stietcli.'s  of  widl  i.reserved  ei)itiielinm  and  beautiful  nuclei,  nearly 
Jill  the  imclei  l)einj:  at  rest.  .\t  otlier  i)la<es  the  nuclei  show  that  they  are  under- 
going most  peculiar  clianges.  without  sh..wiiig  any  particular  changes  as  to  size 
or  f<.rm.  tliey  sJiow  that  they  are  all  more  or  less  advanced  in  imdergoing  a 
change  into  a  homogenous,  reddisji  l)n>wn.  liiglily  refracting  substance,  so  that 
but  one  portion  has  taken  up  tlie  blue  .-oloring  matter.  Due  to  this  change,  the 
chromatic  substan<e  is  gradually  i)usiie(l  into  a  very  narrow  peripheral  zone. 
The  contours  of  tlie  cells  are.  liowever.  well  detined  and  distinctly  seen.  When 
the  nucleus  has  undergone  a  eomplete  change,  owing  to  the  taking  up  of  ma- 
terial from  without,  it  becomes  enlarged,  but  for  a  considerable  time  it  r*'tains 
its  globular  form.  Tlie  protoidasmie  portion  of  tlie  cells  gradually  disappears, 
since  the  globular,  glassy  diyalinei  masses  whicli  till  out  the  nuclei  touch  each 
other,  and  finally  m.-lt  int..  <.iie  mass.tlius  forming  the"l>rusig"  (h.valinet  figures, 
which  assume  the  most  characteristic  forms,  and  frequently  extend  over  large 
areas.  In  th.'se  globular,  at  times  t1attem>d  "nrusen."  1  have  found  stained 
nuclei  enclosed.  In  all  cases  liiey  are  siirrouiKh'd  at  tlieir  edges  by  nuclei,  show- 
ing .'vidi'iues  of  karyokiiK'sis.  Soinet lines  the  nuclei  are  smaller,  tlieii  again 
larger,  and  can  lie  plainly  seen  to  surroiiiHl  th.-se  excresences. 

This  capsule  sliowed  ili.-se  formations  in  all  their  various  stages,  beginning 


la  Untersuchimgen  uber  die  (Jlasluite  d.-s  .\uges.  etc.:  und  Uber  die  Anato- 
mische  Verhaltnisse  des  Kapselstaars.  Wttrzburger  Sit/.ungsberichte.  1850.  p. 
254. 


84 

with  the  isolated  nuclei  just  begiuuing  to  show  ohaugcs  up  to  the  complicated 
formations  1.5  mm.  in  length,  1  mm.  in  width,  and  0.5  mm.  in  height.  At  times 
this  colloid  (V)  substance  is  covered  with  stained  nuclei;  again  but  a  few  are 
scattered  around  the  base  and  edges;  again,  the  interior  of  the  hyaline  mass  is 
perfectly  free,  with  but  a  few  nuclei  scattered  around  the  edges. 

It  is  not  often  that  one  has  tlie  opportunity  of  observing,  as  in  the 
above  specimen,  so  distinctly,  through  all  its  stages  of  development,  thv^ 
development  of  these  hyaline  masses  out  of  the  nuclei  of  the  epithelium. 
There  is,  however,  scarcely  a  capsule,  covering  a  senile  cataract  which  has 
existed  for  any  length  of  time,  on  which  one  can  not  discover  various  stages 
in  the  develoi:)ment  of  tliese  hyaline  excresences. 

The  frequency  of  this  anatomical  condition  corresponds  to  the  round, 
white,  light  reflecting  .spots  frequently  observed  on  the  inner  surface  of  the 
anterior  capsule,  in  over-ripe  cataracts,  mention  of  which  was  made  above. 

B.  NEW  CELLULAR  FORMATIONS  WHICH  DEVELOP  FROM  THE 
INTRACAPSULAR  CELLS. 

a.  REGENERATIVE  NEW  CELLULAR  FORi\L\TION.  ' 
In  close  proximity  to  the  above-described  hyaline  excresences  (Dru- 
sen),  one  always  finds  a  greater  or  less  numl)er  of  luu-lei  which  take  the 
stain  with  avidity,  are  small,  and  show  karyokinetic  figures.  Not  infre- 
quently one  finds  perfect  nests  of  these  nuclei.  On  focusing  these  very 
carefully,  one  discovers  tliat  they  are  no  longer  in  the  same  niveau  as  th'; 
capsular  epithelium,  bnt  seem  to  ascend  on  the  sides  of  these  excresences. 
In  cases  in  which  these  Drusen  are  very  extensive  on  the  inner  surface  of 
the  capsule,  these  new-formed  cells  often  take  on  great  dimensions.  They 
not  only  completely  cover  these  excresences  on  their  inner  surface,  but 
they  seem  to  project  into  its  very  substance.  JJoii-rrrr,  it  stIJJ  iriiiains  a 
question,  whether  these  excresences.  surromuted  as  llieij  tire  l)j/  strands  of 
cetts.  are  nut  from  ttteir  reri/  betjinainn  forniat  from  othrr  celts  irhic't 
these  enctuse.     Tlius  onr  form  of  capsatar  catdract  is  described. 

J).  TIIF   PIJOCESSFS   AND  PJfODl'CTS  OF  ATROPHIC   XFAV 
( '  IvL  1  .ULA R  FORMATIONS. 

Aside  fidiii  tlic  above-described  cellular  new  formations  around  the 
hyaline  cxci'esonccs.  lU'cker  states  that  lie  was  siicccssriil  in  finding  on  the 
inner  siii-racc  of  cvci'v  senile  cataract  wliich  lie  cxaiuinod.  itcir  ccttiitar 
formations.  As  they  lia\c  e.xci'ptionally  been  (it)ser\e(l  in  lenses  which 
showed  no  i-loudiness.  they  can  ]iot  he  looked  u|)on  either  as  the  cause  of 
cataract  formation,  or  as  one  of  its  sc(|nences.  Wo  ralliei-  suggest;-  that  the 
same  cause   which,   dui'ing   the  senih'  >ch'rosi>.   is  acli\('   in    pi'oilucing  the 


■S5 
leiiticuhii-  catiirjicl..  lil<c\\i>c  iiiducis  lliis  new  cflluhii-  roniial  ion.  Ho 
further  makes  the  emphatic  statement,  that  (ill  >inr  fnnndlidtis  of  rxlls 
ivilliin  l/ir  II II ill/ II red  cd/isiilr  iilinii/s  hilrr  llirir  (irhjiii  fnuii  llir  rellular 
('h'liii'iils  irliicli  lire  iKiniidlli/  prrsriil.  Iluil  is.  fnnii  llir  <ii /isiilnr  epi- 
tlii'liiiiii  ill  ils  iiKiri'  rcsl rifled  snisi\  fiirllirr  fmiii  llir  crlls  uIoikj  llir  irhorl, 
0)1(1  jHissihli/  from  lliosr  crlls  irliirli  liiirr  hrronir  cliii iii/nl  iiihi  /Ihrrs.  As  a 
rcsnh  (if  tliis  active  hy|)ei-|ihasia.  we  meet  with  an  rpillirlinl  corrriiui  on 
llir,  iiiiirr  siirfncr  of  llir  poslrrior  rd/isiilr:  also,  hiri/r  rrsiriiUir  rrlls  whicli 
are  J're(|uenlly  h)eate(l  hoth  in  the  anteiior  and  posteiior  coi'tical  substance: 
also,  nrsis  of  llirsr  ai'e  at  limes  fouiKl  ///  llir  rijiinlorinl  rri/ioii.  which  frroatly 
simuhite  the  hyalini'  excreseiices  spoken  of  above,  as  well  as  the  Irne 
capsular  calararls. 

'rhei'(»  are  various  methods  of  pi-ovin;^-  that  there  is  a  hyperphasia  of 
the  epithi'lium  during;-  the  foi-malioii  of  cataract.  Xuch-ar  fission  is  un- 
doubted evich'iiee.  Dui'ing-  the  whoh'  of  life.  1h<'  size  and  form  of  the 
nuclei  of  a  normal  human  eai)snlar  e])ithelium  show  an  astonishing  reg- 
ularity. .\  surface  view  shows  them  to  1)e  circular  and  with  a  diameter  of 
0.00.")  nun.,  and  equally  far  removed  on  all  sides  from  the  l)orders  of  the 
protoplasm.  Therefore,  when  in  a  case  of  cataract  we  iind  a  portion  of  the 
epithelium  of  absolutely  normal  size,  form  and  position,  and  again  in  other 
places  find  the  size  of  the  cells,  their  form  and  their  nuclei  materially 
changed  from  the  normal,  this  of  itself  is  evidence  of  a  hyperpha.sia,  a 
pathologic-al  new  formation,  even  when  the  cells  are  found  where  epi- 
thelium is  noi-mally  found  and  when  ari-anged  as  a  single  layer. 

a.  KPlTlllvLlAJ.  ('()\EJJJX<;  OF  THE  roS1^KTM()l{  CAPSl'LE. 

AVhen  e])ithelial  cells  are  fouml  at  places  where  under  normal  condi- 
tions they  are  absent,  there  can  be  no  doubt,  but  that  we  are  dealing  wit.'i 
a  new  cellular  formation.  Even  IT.  Muller  observed,  that  at  times  in  cata- 
ractous  lenses  a  layer  of  epithelium  clothed  the  inner  surface  of  the 
posterior  ca])snle.  Iwaiiotf,  (iayei.  liecker  and  others  verified  this  state- 
ment years  ago. 

H.  Muller  (cited  al)ove.  p.  2(^9)  stales.  -'Hiere  ai)]H'ars  also  to  be  a 
hyperphasia  of  cells,  as  1  have  several  time>  found  a  layer  of  irregular 
cells  on  the  postcjior  ca])sule."  lie  refers  to  this  again  in  his  following 
publications  (pp.  -iiil,  •^(iO,  'i::.  -i^o).  IwanolV  studied  this  condition  of 
the  epithelium  in  eyes  which  had  been  enucleated  on  account  of  disease. 
He  states/  '"The  cells  which  are  most  sensitive  and  earliest  affected  by 

IBeitrag  zur  Path.  Anatoniie  des  HernhaiU  uud  Linsen  Epitliel.  racren- 
stechers  Klin  Beobachtungen,  Bd.  III.  p.  12(!. 


86 

irritation  are  the  formative  cells  of  the  h'ns."  Every  time  one  of  the  above 
diseased  conditions  begins  to  act,  tlic  lens  swells  and  the  formative  cells 
are  affected.  Tlie  piodiict  of  these  formative  cells  is  normally  epithelial 
cells  arranged  on  the  innci-  surface  of  the  anterior  ca])sule.  as  new  lens 
fibres  and  as  r/iillirli iiiii  on  Ihe  /los/rrinr  r<i psiilr.  'i'his  new-formed  epi- 
thelium seldom  has  the  attrilmles  of  normal  epillieiium.  In  most  cases 
it  ap|)eai'>  more  swollen,  the  nuclei  easily  nndei'go  fission,  and  in  fact  ap- 
pears to  ])ossess  but  little  viability(?).  The  ei)ithelium  on  the  posterior  cap- 
sule easily  undergoes  degeneration,  (colloid,  mucoid),  hence  one  so  often 
sees  these  large,  transparent,  variously  shaped  vesicles,  containing  a  nucleus 
which  has  been  pushed  to  one  side." 

II.  Mil  Her  made  all  his  investigations  on  cataractous  lenses.  Ifence  it 
is  of  interi'st  to  note  that  he  likewise  drew  attention  to  the  ra])id  disintegra- 
tion of  the  nuclei  of  these  new-formed  epithelial  cells,  and  he  likewise 
looks  u])on  the  equatorial  zone  as  tlieii-  source  of  origin.  (Jayet-  likewise 
investigated  the  question.  He  believed  that  as  a  result  of  the  formation  of 
these  vesicular  cells,  which  are  altei'cd  epithelial  cells,  the  neighboring 
normal  epithelial  cells  are  pushed  aside,  and  as  a  i-esult  are  found  alon.r 
the  posterior  c^apsule. 

Becker  states  that  he  is  satisfied  that  "the  epithelial  covering  of  the 
posterior  capsule  is  derived  from  the  surface  growth  of  the  antiM'ioi'  epi- 
thelium. This,  however,  can  only  begin  to  act  when  the  lens  whorl,  as 
such,  has  ceased  to  exist."  He  denies  the  existence  of  the  so-called  fnniKt- 
tive  cells  m  the  sense  in  which  von  Keeker  used  them:  he  states,  however, 
that  "the  pathological  ])roduction  of  new  cells  takes  ]>lace.  nevertheless, 
from  that  region  where  m)rmally  the  growth  and  regeneration  of  the  epi- 
thelium takes  ])lace.  The  cells,  howevei-.  as  they  are  forced  backward,  are 
not  changed  into  lens  fibres  tlir(nigh  tlu'  medium  of  the  lens  whorl,  since 
either  the  lens  whorl  no  longer  exists,  or  since  the  meebanii-al  condition-- 
themselves  are  changed.  As  a  result,  the  cells  are  pushed  past  the  positioti 
of  the  whoi'l.  far  backward,  and  thus  to  a  gicater  or  less  extiMit  cover  the 
innei-  surface  of  the  posterior  capsule.  On  this  account,  changes  along  the 
lens  whoi'l  in  catai-acts  are  of  great  imporlaiice.  In  fact,  it  st'cms  that 
whenevei-  a  cataract  has  advanced  to  atiy  degi 
the  whorl   and  the  capsule,  also  with   the  youn 

The    mechanical    conditions   are   changed 
need    no    loiigei'  o\erconie   >o   much    pres>ui'e.  and    ih 
themselves  on   the  one  hand   in   between   the  cji 

2  Sin-     nil     I'oiul     d"!  listolu-ie   dc     la     ( ':it:ira<-t( 
XXXUl.  1).  ir.. 


Ihc 

connection 

between 

libl 

e>.   is   loose 

lU'd    up." 

far. 

that    the    1 

lew    cells 

hu> 

can    pu-li   ; 

n.l    fonv 

eliui 

n   and    the 

posterior 

87 
capsule,  aiul  the  lens  lihi-cs,  on  I  lie  oilici-  liiind,  i-clativcl  v  >|»c;ikiii^-,  willidiit 
any  hiiulranee  wliatevei-.  and  iiiidci-  imicli  less  pressure,  lieiicc  tliey  develop 
into  the  lai'uc  vesicular  cells  dii'cclly  to  he  descrihed.  or.  as  epilhelial  cells, 
perniil  themselves  to  push  hackward  lo  the  posterior  capsule.  In  eonipli- 
oated  cataracts  one  can  often  accuratelv  follow  the  direction  which  thev 
take. 

As  t-onipart'd  with  ihe  epithelial  cells  on  the  po>lei'ioi-  capsule  which 
disclose  departures  from  the  normal,  we  fri'(pieiitly  meet  with  vesicular  cells 
in  the  region  of  the  whorl. 

Thei'e  can  be  nt)  doubt  but  thai  these  new  cells  again  produce  cells. 
Xot  only  are  tlie^e  large  vesiculai-  cells  formed,  but  in  rare  cases,  structures 
whicli  are  identical  with  the  so-called  capsular  cataracts  of  the  anterior 
capsule.  r>orh  the  pseudo-epithelium  on  the  postei'ior  capsule,  as  well  as 
those  vesiculai-  cells  along  the  i'<pialor.  show  the  pi'csence  of  elongatt'd 
nuclei  pooi'ly  stained,  the  karyokinetic  changes  very  indistinct  and  the 
cells  very  much  enlarged.  Becker  ex})resses  the  l)elief  that  these  cells  may 
reproduce  other  cells,  but  at  the  same  time  acknowledges  that  he  never  ob- 
served karyokinetic  changes  in  the  nuclei  of  the  pseudo-epithelium  nor  in 
the  vesicular  cells. 

h.  WKDIAS  VKSICULAK  CKLLS. 
r.LA8CHKXK()HMl(;KX  ZKLLKX.  'Vhv^v  cellular  vesicK's.  which 
were  iirst  described  by  W'edl  and  later  by  Iwanotf.  Knies  and  others,  have 
a  twofold  origin.  They  are  either  products  of  the  posterior  ca[)sule.  or  the 
cells  at  the  whorl  whicli  have  uiulergone  enormous  distension,  or  they  are 
developed  from  the  fully-develo])e(l  lens  libres.  due  to  a  very  peculiar 
change  in  the  contents  of  the  fibre  around  the  nucleus.  'I'hese  cells  are 
never  found  wanting  in  examination  of  senile  cataracts,  especially  in  the 
diabetic  and  congenital  cataracts. 

Xeither  Wedl.  Jwam)tf,  Knies  nor  JJeckei-  oil'er  an  explanation  as  to 
their  origin.  The  only  oiu'  who  has  decided  their  oi'igin  is  (Jaylet.^  Ho 
believes  that  during  ihe  formation  of  a  capsular  cataract  he  has  discovered 
similar  changes  to  those  wliich  11.  Leloii'^  has  described  as  occurring  in  the 
rete  malpigi  during  the  formation  of  small])o.\  pustules. 

'•Around  the  nucleus  of  the  cell  there  is  (h'vehjped  .1  whitt'  zone,  wliieh  lirad- 
nally  enlarges  jtt  the  expense  of  tlie  protoplasiu  of  the  cell,  at  the  same  time 
pressing  the  nucleus  to  one  side,  and  tlius  materially  enlarging  the  cell.     Thus 

3  Sur  tni  Tolnt  d'llistologie  de  hi  l'at:iraete  Cap'^ulaire.  Lvon  Med.  XXXIII. 
1).  15. 

4  Coutrihutiou  a  I'etude  Formation  des  Pustules  et  des  Vesieules  .sur  la  peu 
et  les  Mutiueuses.    Arch,  d  Physiologie  Normal  et  Pathologic,  1880,  p.  307. 


88 

the  roll  l)ccouH>s  changed  into  a  vesicle,  in  which  the  nuclens  atrophies,  and 
gradnally  nndergoes  a  fatty  defreueration.  These  greatly  enlarged  vesicular 
cells,  owing  to  pressure  against  each  otlier.  assume  polyhedral  shapes,  and  press 
those  cells  which  have  not  undergone  such  a  change  into  characteristic  angular 
shapes;  they  then  become  granular,  and  tiually  disappear.  This  vesicular  de- 
generation of  the  epithelial  cells  necessarily  leads  to  a  surface  enlargement  of 
the  entire  epithelial  layer,  and  according  to  Gayet  explains  the  cause  for  the 
spreading  of  the  epithelium  to  the  posterior  capsule." 

Becker  denies  that  lie  has  ever  noted  such  changes  during  the  forma- 
tion of  these  vesicular  cells,  and  states  that  we  do  not  as  yet  possess  a 
satisfactory  explanation  of  this  peculiar  change.  Is  this  hyaline  or  colloid, 
or  is  it  a  peculiar  hydropsie  of  the  individual  cells? 

The  vesicular  changes  are  most  easily  studied  along  the  equatorial  line 
of  secondary  cataracts,  and  in  all  probability  a  study  of  their  development 
here  will  aid  us  in  clearing  up  the  processes  which  form  the  basis  of  this 
change.  Since  the  days  of  Yrolick  and  Sommering  we  know  that  after  a 
reclination  or  extraction  the  cells  along  the  lens  whorl  remain  in  the  cap- 
sule. After  the  operation  the  production  of  cells  springs  up  anew.  How- 
ever, the  mechanical  conditions  being  changed,  these  cells  become  flat,  and 
on  cross  section  are  no  longer  six-sided  lens  fibres,  but  assume  irregular 
polyhedral  shapes,  similar  to  the  vesicular  cells  found  in  cataracts  within 
uninjured  capsules.  The  pressure  being  removed,  the  lens  fibres  along  the 
equatorial  region,  those  which  have  remained  dormant  for  years,  become 
active  again,  and  now  being  developed  under  a  reduced  pressure,  do  not 
form  fibres,  but  assume  polyhedral  shapes.  Becker  describes  a  second 
mode  of  development.  A  peculiar  change  of  the  protoplasm  around  the 
nucleus  occurs  in  the  cells  at  the  equator.  It  becomes  thickened,  more 
highly  refractive,  inA^olves  either  the  entire  thickness  of  the  fibre,  or  leaves 
a  portion  of  the  substance  of  the  fibre  to  one  side,  and  thus  seems  to  be- 
come constructed  at  first  into  an  ellijitical,  finally  iuto  a  globular  disk.  All 
this  time  the  nucleus  appears  to  be  at  rest.  Xotwithstanding  the  great  dif- 
ference which  exists  regarding  the  mode  of  development  of  the  vesicular 
cells,  the  question  must  still  remain  an  unanswered  one.  as  to  whether  they 
possess  anything  more  in  common  than  their  form.  Concerning  the  rela- 
tion of  these  cells  to  cataract  formation,  these  di (Terences  are  of  but  littlo 
moment,  since  the  cells  developed  according  to  the  second  method  are  very 
few. 

'^i'he  large  cells  are  especially  ])r(uie  to  dcgeiuM-ation.  Their  nuclei 
show  all  the  evidences  of  a  gradual  death.  The  hordcrs  of  the  cells  become 
indistinct  and  the  conteiils  (»!'  ncighhoring  cells  i-un  togclher.  rorniiug  a 
homogenous  jnass.     JwanolT  (b'signated   this  change  as  colloid  or  ntucoid. 


•S9 
Since  the  occurroiiee  of  mucin  in  llic  capsule  sac  lias  nur  been  jn'oven  and 
since  this  chanii^ed  product  does  not  give  the  reaction  of  colloid  material, 
both  names  are  improper.  Becker  states  that  it  would  he  more  correct  to 
speak  of  them  as  hydropsical  cells.  Tlie  supposition  that  the  disintegra- 
tion of  the  vesicular  cells  aids  in  l)i'iimiii,i;-  iihout  the  tlnidily  in  cases  ot 
cataracta  ^lorgagni  has  uiuch  in  il>  favor. 

Becker's  view,  tliat  all  ca|)>ular  cataracts  are  the  result  of  a  h3'per- 
plasia  of  the  capsnlar  epiiht'linm.  is  today  accepted.  He  believed  (Anat- 
omy, p.  7«i)  that  the  hyahiie  processes  of  the  newly  developed  cells  in  some 
manner  softened  up  the  ca])sule.  worked  their  way  in  between  the  layers  (?) 
of  the  capsnle.  thus  splitting  it.  and  that  the  capsular  cataract  then  de- 
veloped in  this  sijace. 

As  long  ago  as  1S.5S,  H.  ^lullcr  di'ew  attention  to  the  great  similarity 
between  capsular  cataracts  and  connective  tissue,  and  np  to  within  a  few- 
years  this  formed  one  of  the  nicest  questions  in  the  whole  range  of  the 
study  of  ocular  |)atliology.  (leneral  patluilogy  teaches  that  connective 
ti.ssue  structures  must  he  forjned  from  cells  of  tlu'  mesoderm,  and 
hence  can  not  be  derived  from  the  ectoderm.  Manfredi  ^  attempted  to 
overcome  the  difficulties  in  the  way,  by  declaring  that  a  capsular  cataract 
could  only  form  after  an  injury  to  the  cajisule,  and  where  it  had  been 
made  possible  for  cells  of  the  mesoderm — that  is,  connective  tissue  cells — 
to  gain  entrance,  and  thus  further  produce  connective  tissue  cells;  and 
thus  he  positively  asserts  that  capsular  cataracts  is  a  connective  tissue 
structure.  Leber  ^  bases  his  utterances  on  examination  made  on  capsular 
cataracts  experimentally  ])roduced.  He  expressly  states,  that  he  excluded 
all  elements  which  might  have  entered  from  without.  Notwithstanding 
this,  he  designates  the  tissue  of  a  "true"  or  "genuine"  ca])sular  cataract  as 
connective,  Ussne-lil-e.  and  states  that  he  verified  to  his  own  satisfaction 
"that  from  a  tissue  which  originates  from  the  ectoderm,  hence  which  is  a 
true  epithelial  tissue,  a  substance  can  be  produced  which  has  the  structure 
of  connective  tissue."  Becker  struck  the  pro])e]-  chord,  when  lie  pointed 
out.  that  this  question  would  eventually  he  settled  as  the  roult  of  chemical 
investigation. 

The  question  presents  different  features  when  there  has  been  a  solu- 
tion of  continuity  of  the  capsule.  Here  one  can  not  so  easily  exclude  the 
entrance  of  foreign  elements.     Nevertheless,  as  the  result  of  two  series  of 


i  "Discussion  sur  la  Cataraete  Capsulaire."  Compte  rendu  du  Congres  Pe- 
riodique  Internat.  d  Opthal.  de  Milan,  1881. 

5"Zur  Pathol,  der  Linse."  Zehender's  Kliu.  MonatslMatt.  Beilaslioft.  p.  33. 
Verb,  der  Heidelberg  Gesell,  1878. 


90 

experimental  iiivesti^^ations  piir.-ucd  uiidei-  the  direction  of  Prof.  Leber, 
R.  Wengler,^^  and  II.  Soluichard.-''^  the  |)osition  was  taken  that  capsular 
circatrices  are  due  to  a  liyperj)hasia  of  ca])sular  e[)ithelinni.  whereas  in  a 
later  work  by  ('.  Scldosser  •'''■  tlie  old  \iew  is  asserted  that  the  cicatrix  is 
of  coiinective  tissue  ori>rin.  He  states  that  tiie  ca))suhir  cicatrix  is  made 
up  of  connective  tissue  fibres,  tbe  only  portion  which  is  of  epitbelial  origin 
being  the  layer  of  epithelial  cells  and  tlie  structureless  membrane  which 
separates  the  cicatrix  from  the  lens  proper.  Uut  he  ignores  entirely  the 
question,  from  whence  these  connective  tissue  cells  may  come.  This  whole 
subject  has  finally  been  most  scientifically  investigated  by  Otto  Schirmer.^ 
He  first  studied  the  formation  of  artificially  produced  capsular  cicatrices 
in  i-abbits*  eves. 

CAPSULAR  CICATRICES. 

Immediately  upon  rupturing  the  capsule,  the  aqueous  acts  on  the 
lens  fibres,  c-auses  them  to  swell  up.  and  unless  the  rupture  is  very  great, 
the  opening  is  soon  plugged  up  by  a  thin,  fibrinous  covering  which  clothes 
the  point  where  the  defect  in  the  capsule  exists.  Examinations  made  dur- 
ing the  first  few  days  show  present  in  this  fibrinous  exudate  two  kinds  of 
nuclei:  first,  degenerated  forms  of  epithelial  and  lens  fibre  nuclei,  and  sec- 
ond, a  few  leucocytes.  Schirmer  states  that  he  found  a  fully  formed 
cicatrix  as  early  as  the  third  day.  He  looks  upon  this  regenerative  process 
as  the  result  of  a  liyi)erphasia  of  the  capsular  epithelium  because:  First, 
the  defect  heals  from  the  margin:  second,  the  cicatrix  gradually  goes  over 
the  nonnal  capsule;  third,  because  at  the  beginning  the  cicatrix  has  a  j)e 
euliar  structure  consisting  of  spindle  cells  without  the  presence  of  an 
intercellular  substance:  fourth,  because  of  the  possibility  of  demonstrating 
all  the  gradual,  internu^diate  steps  between  epithelial  and  s])indle  cells: 
hfth.  the  epithelial  a])pearance  of  the  nuclei  in  the  cicatrix:  sixth,  the  lack 
of  pigment:  and.  linally,  seventh,  because  of  the  relatively  small  number  of 
cells  found  in  the  fibrinous  membrane  which  have  a  different  appearance 
from  the  general  mass  of  cells  found  in  the  cicatrix." 

Following  the  formation  of  the  cicatrix,  the  filu-inous  veil  on  the  sur- 
face is  absorbed  by  the  a(|Ucoiis.  and  no  doubt  the  cells  which  it  encloses 
are  destroyed  at  the  same  tiuu'.     In  the  courst'  of  the  next  few  weeks  thi- 

5a  L'ber  die  Helhuifrs  Vorjranjre  nacli  Verlctznniicn  dcr  Vodcvn  I>iuspnkaps«'l. 
Inaug:.  Dissert.  (Joettiuficn.  1.S74. 

5b  "Zur  Path.   Anatoiiiic  der  Discission."     Inaiij.'.    Dissert.   (Jocttiiijjjeii.   1ST8. 

5c  Experimentellc  Studi«'  uber  Trauniatische  Cataract.    Mnnchen.   1887. 

6  "Histolojrisclic  und  IlistoclK'niisclie  rntersuchungen  uber  das  IMiysiolo- 
jjische  Wachstlmiii  und  (lie  Structure  d.>i'  N'odcrii  Linsenl^apsel."  Otto  Scliirnicr. 
<5raef  Arch.,  XX.W.  I'..  1.  iss'.i. 


I 


91 
ciciiti'ix  ,i:ivcs  diic  tlic  iiiiprosioii  kF  Itccdiniiii:  >iii;illci-.  Alxml  the  middle 
..r  the  (ii'st  iiKUilli,  (MIC  ohxM'vcs  tli;il  llic  ('|iil  licli  iini  -r;i(lii;i  lly  cxh-nds  ;is 
;i  .-inylt'  liivci-  nwv  the  iniifi-  siirrjicc  (if  the  citiiliiN.  iiiiljl  it  liiuillx 
i'iitii-('Iv  coNci-.s  ill  llic  cicjitrix.  At  once  the  cpit  licliiiiii  l)c,i;iii>  lo  cxcrcU' 
a  vitrctMis  laiiiclla  (if  new  capsular  siil)>tancc.  wliicli  i^radiially  increases  in 
lliickiios.  and  in  cvcrv  case  this  new -formed  >iil)>taiice  can  lie  followed 
for  a  cei'tain  distance  on  to  the  old  ca|isiilc.  In  the  he-inning-  we  are 
dealin,u-  with  spindle  cells,  later  they  arc  imheddcd  in  a  livaline  substance 
which  the  >piii(lle  cells  excrete.'  in  course  of  lime  the  nuclei  all  disap- 
pear and  thei'c  i>  left  a  homo.yeiious  cicatrical  tis>iie.  covered  hy  a  layer 
of  epithelial  cells  and  the  vitreous  lamella,  and  with  this  sta.ue.  the  process 
of  the  formation  of  a  capsular  cicatrix  is  coni|)leled.  As  a  rule,  the  injury 
causes  a  minute,  circumscript  area  of  disinte.yral  ion  of  lens  tissue,  siir- 
rouiuled  hy  transparent  lens  substance,  and  as  the  new  lens  fibres  develop 
and  increase  in  lcii,i:th  and  extend  toward  the  anterior  pole,  they  force 
their  way  between  the  cicatrix  and  the  mass  of  detritus,  so  thai  a  "cavity 
of  detritus"  is  formed  which  is  gradually  forced  towai'd  the  centre  of  the 
lens. 

THUE  CAPSULAR  CATAliACJ'. 

Here  there  has  never  been  a  rupture  of  the  capsule,  hence  tliere  can 
be  no  ([uestion  as  to  the  origin  of  tlie  new  structure,  it  being  the  result 
entirely  of  the  hyi)erplasia  of  ei)ithelial  cells.  It  is  immaterial  whether 
this  be  a  congenital  formation;  that  is,  developed  during  foetal  life;  whether 
it  develop  during  childhood,  be  the  residt  of  a  blenorrhoea  neonatorum 
or  otherwise  caused  corneal  perforation,  a  primary  cataract  formation,  or 
secondary  to  senile  cataract,  or  whether  it  l)e  a  partial  phenomenon  of  a 
rafanirht  nuisrciil I ra  or  the  principal  portion  of  a  ralfinirhi  s(rundaria(M\\\ 
to  l)e  considered)  or  of  a  traumatic  cataract  (as  has  been  demonstrali'd 
above),  (ill  (itr  llw  result  of  a  InuMT/ilntsid  nf  llir  rd psiiJar  ('pilhcliinii. 

lU'cker  states  (Anatoinie.  p.  l.")).  ••Depending  on  some  cause  as  yet 
unknown  to  us,  this  byperpla>ia  may  at  once  undergo  a  retrogressive 
metaiiKU'phosis.  and  as  a  result  of  a  repetition  of  the  m'iginal  process  lead 
to  the  formation  of  a  capsular  cataract  of  a  greater  (U-  less  thickness."  The 
original  hyper])Iasia  of  e])ithelial  cells  may  be  looked  upon  as  the  first 
stdfic  Next,  thcsi-  cells  elongate  and  take  on  spindle  shapes,  not  roniwrlire 
tissue),  and  imbed  themselves  in  a  peculiar  hyaline  s\d)stance  which  they 
themselves  excivte,  and  this  forms  the  seroud  sifuje.  This  is  followed  by  a 
surface   growth    across   this   new   formation    of   the    normal    capsular   epi- 


7  Leber— "Znr  Patholofrie  der  I.iiise."    Bericlit  der   lltli   Opth.   (lesellshaft, 
ITeidelbcrs.  ISTS. 


92 

tlieliuin.  till'  third  sIikjc.  and  finally  tliis  normal  ('})itlR'liuiu  excretes  a 
livalinc  siil)staiice.  cwaetly  like  llu'  true  capsular  substance,  the  fourth 
sldf/e.  If  the  causative  factor  continues,  a  second  capsular  cataract  may 
develop  from  this  epithelial  layer,  etc.  Becker  tried  hard  to  prove  that 
the  membrane  which  covers  the  capsular  cataract  is  derived  from  a  splitting 
of  the  true  capsule.  Schirmer,  however,  showed  that  this  theory  is  not 
tenable,  because,  first,  ''this  is  an  excretion  -of  the  capsular  epithelium; 
secondly,  why  should  it  be  possible  for  cells  to  get  in  between  the  layers 
and  split  the  vitreous  lamellae  from  within,  when  it  has  been  shown  to  be 
an  impossibility  to  do  so  from  without?  Further,  these  splits  could  only  be 
followed  as  fine  lines,  but  no  one  ever  observed  a  veritable  se])aration.  nor 
has  anvone  ever  recorded  the  observation  of  the  beginning  of  such  a  split."* 
The  fact  that  one  seldom  finds  the  capsular  cataract  completely  covered 
with  epithelium  is  possibly  due  to  the  growth  of  the  cataract.  The  age  of 
the  patient  may  play  an  important  role,  for  Schirmer  noted  that  in  senile- 
cataracts  the  epithelial  covering  of  the  capsular  cataract  is  not  so  com- 
plete as  in  the  complicated  cases  which  occur  most  frec[uently  in  younger 
individuals. 

The  structure  of  the  true  capsular  cataract  bears  a  striking  likeness 
to  connective  tissue.  Teased  specimens  morphologically  were  shown  ti 
have  the  same  structure  as  the  capsular  cicatrices. 

Schirmer,  using  Ewald  and  Kuhne's  digestive  method  (referred  to  on 
])age  ^(i)  as  his  main  stay,  chemically  tested  capsular  cicatrices  and  cap- 
sular cataracts  and  found  them  both  to  consist  of  identical  tissue,  whicli 
does  not  give  the  same  reaction  as  connective  tissiie.  Both  gave  the  same 
reaction  as  the  capsule,  a  not  inconsiderable  proof  that  the  capsule,  as  well 
as  its  pathological  formations,  are  derived  from  the  same  source,  namely. 
prodncts  of  the  epittudliiiii  of  the  nutorior  capsule. 

Schirmer,  usins  a  very  simple  apparatus,  made  liis  experiments  in  the  fol- 
lowing manner:  Two  small  dishes,  one  a  little  larj;er  than  tlie  otlier,  were 
placed  on  top  of  each  other,  so  as  to  form  a  wet  chamber.  A  third  smaller  one 
was  placed  inside  of  these,  and  this  latter  was  covered  with  a  glass  slide.  Dur- 
ing the  experiments  just  sufficient  fluid  (salicylic  acid  solution,  0.5  per  cent.)  was 
placed  in  tlie  wet  chamber  so  as  just  to  toncli  the  glass  slide.  The  digestive 
process  was  either  carried  on  in  the  small  dish,  or  more  frequently  on  the  glass 
slide.  In  the  latter  method,  the  cover  glass  was  supported  on  the  one  side  by 
a  piece  of  glass  fastened  to  the  slide,  tlius  forming  a  triangular  chamber,  in 
which  the  object  to  be  tested  was  itlaced.  .md  here  it  could  likewise  be  ob- 
served under  liigli  poweis  of  the  luicroscope.  'I'he  digestive  solution  was  made 
from  the  extract  of  llic  i»aiirreas  of  the  calf,  to  wliich  was  added  five  times  its 
weight  of  a  (>.."•  per  cent,  solution  of  salicylic  acid,  and  then  l<ept  for  several 
lionrs  at  4(»  degrees  ('..  and  after  tliis  had  cooled  it   was  tiltered. 


93 
He  first  vcrilit'd  Kuliiic's  cxpcriiiiciits.  mihI  .-ilso  rniiml  ili.-it  roiiiiniivf  tissue 
is  not  ai,qest:il)l(':  hut  lli:it  it  is  cnsily  (li,t;('sl;ii)l('  W  pi-cvioiisiy  iicidiiljilcd.  :iu(l 
then  heated  to  7<>  ilc.iii-t'cs.  ('(.nlrol  cxiici-iiufiiis  were  iii;idc  ;il  ilic  smmic  tiiur  wiili 
normal  capsular  substance.  XoniiMl  cniisulcs  of  iiius"  and  raiiliits"  Icuses  were 
easily  di.uested  in  from  five  lo  six  liours.  Allowing  ilicm  to  i-i'inaiii  in  aicoliol 
for  eiirlit  days  did  not  alter  this  power,  wlicrcas.  if  .iliowcd  lo  i-ciiiaiii  for  several 
montlis.  tile  tissues  were  decidedly  more  resisieul.  .-lud  always  leli  a  liaky  mass 
behind.  If  llie  sections  were  imbedded  in  celloidin.  they  could  be  iefi  foi-  days 
in  the  dificstive  fluid  without  beinj;-  aeled  on.  Since  alcohol  and  etlier  did  not 
delay  the  dijjestion,  one  must  assume  tliai  the  celloidin  penetrated  the  rjssue 
and  made  it  indijrestablc.  If  tlie  capsule  was  previously  treated  witii  1  per 
cent,  osmic  acid  solution,  ilieii  waslied  out  in  watei-.  the  capsule  l»ec;imc  more 
resistant,  and  all  tlu'  more  so  the  louder  the  capsule  had  remained  in  tlie  osmic 
acid. 

Capsular  cicatrices  and  capsular  cataracts  nave  identically  the  same  reac- 
tion to  trypsin  as  did  tlie  normal  cai)side. 

77/r  HoiliiKj  Experiment.— It  is  well  known  that  boiliii.u  will  lead  to  a  solution 
of  tibrillae.  and  on  cooling  lead  to  the  formation  of  a  .jelly.  Accordinii'  to  Arnold 
and  Ritter.s  after  boiling  for  several  houis.  a  solution  does  take  place,  but  no 
jelly  forms  on  cooling.  One  centimeter  of  water  is  sufficient  to  dissolve  the 
anterior  capsule.  Capsular  cataracts  and  capsular  cicatrices  showed  the  same 
properties,  but  did  not  form  a  .ielly  on  cooling.  Thin  pieces  of  connective  tissue 
allowed  to. swell  up  in  a  1  per  cent,  sidution  of  sulphuric  acid;  here  the  fibrillae 
dissolve  in  water  at  40  degrees  C.  and  the  floccnli  M-hich  remain  consists  of 
elastic  tissues  and  cells.  The  capsule,  capsular  cicatrices  and  capsular  cata- 
racts do  not  dissolve  in  similar  treatment. 

The  slight  resistance  of  the  capsule  to  strong  acids  is  well  known,  especially 
to  nitric  acid,  which  in  but  moderative  concentration,  can  bring  about  solution. 
The  same  is  true  of  capsular  cicatrices  and  capsular  cataracts.  The  reaction 
is  especially  characteristic  as  compared  with  elastic  tissue. 

Schirmer's  conclusions,  which  are  eeiierally  accepted  today,  are  as 
follows: 

"First.  Capsttlar  cataracts  and  capsular  t-icat rices  devclo]i  front  the 
anterior  capsular  epithelium  without  the  aid  of  otlier  tissues. 

'\Secon(L  Both  are  a  tisstie  sui  tjeneris.  morphologically  like  con- 
nective tissue,  chemically  diifering  from  this,  but  both  capsular  cicatrices 
and  cataracts  are  alike. 

''Third.  Chemically,  a.^ide  from  the  cells.  ])oth  are  identical  with  the 
capsular  substance.      Morpholooically.   both    forms    of    capsular    cataracts 


8  Die  Linse  und  das  Strahlen  Platchen.     Graef  Saemisch  Handbuch.  Bd.  1, 
S.  288  and  21G,  1874. 


94 

consist  of  elon<iatt'cl  Cljaiid-likc")  cell^.  which  arc  iinhedded  in  a  vitreous- 
like  substance.     The  latter  is  a  product  of  the  former. 

"Fourth.  Tlie  j)io;ment  which  is  at  times  found  in  the  cicatrix  is  de- 
rived from  the  iris,  and  is  hirgely  carried  thcic  l)y  the  leucocytes. 

'•Fiflh.  The  delicate  vitreous  lamella  which  is  found  in  the  older 
capsular  cicatrix  and  capsular  cataracts  is  excreted  by  the  epithelial  cov- 
ering, which  in  such  cases  is  always  found  between  the  cicatrix  and  the 
cells.     This  lamella  grows  with  the  age  of  the  cicatrix. 

"Si.rlh.  If  this  lamella  can  be  followed  into  the  capsule  adjacent  to 
the  cicatrix  or  ca])sular  cataract,  one  will  note  that  this  is  not  a  split  in  the 
original  cai)sule.  but  that  this  ca])sular  substance  is  likewise  newly  formed. 
The  line  of  demarcation  between  the  old  and  the  new  capsular  substance 
is  the  oi)tical  expression  of  an  interference  with  the  regular  and  continuous 
excretion  by  the  capsular  epithelium." 

Foreign  substances  enclosed  in  the  capsular  cicatrices  and  cataract*. 
Becker  states.^  "with  the  exception  of  calcareous  concretions,  and 
rarely  observed  cholesterine  crystals  and  very  peculiar  highly  refracting 
masses,  which  for  want  of  a  better  name  he  designated  as  colloid,  no  other 
substances  are  found.  These  are  to  be  looked  u])on  as  the  result  of  disinte- 
gration and  ])rccii)itation.  and  of  chemical  decomposition  in  the  already 
formed  cataracts,  hence  formed  in  situ/' 

"It  is  worthy  of  especial  mention  that  the  calcareous  deposits  are 
always  around  the  cellular  elements  in  the  intercellular  spaces  in  the  form 
of  amor|)hous  granules,  but  at  times  they  form  veritable  deposits  even  to 
actual  formation  of  stalactites  as  H.  Muller  expresses  it.  This  expression, 
however,  may  only  be  con-ect  as  far  as  the  form  goes,  for  stalactites  are 
alwavs  crystalhne  structures  and  1  have  never  seen  calcareous  crystals  iii 
the  lens."     (liecker,  p.  TT). 

As  long  ago  as  IS.'xS.  ^Muller  stated  that  the  capsule  formed  an  abso- 
hite  barrier  against  tin-  entrance  of  foreign  elements.  Becker  likewise  con- 
tended that  as  h)ng  as  the  ca])suh'  remained  intact  it  formed  an  absohite 
barrier  against  tlie  enti-ance  of  any  foreign  body.  At  one  time  it  was  sup- 
posed that  the  capsule  of  the  lens  possessed  stomala.  (Morana).  then  again 
it  was  supposed  that  the  white  hlood  corpuscU's  could  pass  through  the  ca]>- 
,sule  by  (liapedesis.  I  )eutsclnnau  '"  (piotes  Floi'iani  "  as  expressing  himself 
in  favor  of  the  endogenous   fmiuation   of  pus.      Ihuitscliiuan.   however,  do- 


9  Anatomie,  p.  77. 

10  "Dio  ViM-anderunfrcn  in  der  T>inse  bei  Kiterprocessen  im  .\n.i:e."     .\rcli.   f. 
Opth..  B(l.  XXVI.  1.  p.  l.U. 

11  Studio  Kxperinieiitelle  Sulla  IiUlainnial  ione  del  Crista'lino.     Anna  di  Otial, 
]S71.  p.  ]4.-)-1S<t. 


95 

nics  lliis.  and.  like  .liilic  Sindaii-.""  lie  cxplicilly  .-tair-  lliat  llic  entrance 
of  \)\\>  is  always  pi'ccfdcd  liy  dcsl  iMict  ion  fif  llic  capsnlc  Since  the  lens  is 
an  epithelial  stiaictni'e.  the  \)\\>  eelU  iiiiisl  come  IVoni  without.  In  cases 
whoiv  thei-e  had  heen  an  injiirv  lo  the  ca|)>ule.  their  |>i'e.-.ence  was  easily 
oxi)laine(l.  hut  it  has  heen  known  U)V  a  l(ui>:-  time  that  there  are  cases  of 
spontaneous  purulent  inllanimation  in  which  the  presence  of  the  |)us  cells 
could  not  he  so  easily  explained.  The  (pieslion  to  be  decided  was.  did  the 
cells  wander  throu>;h  the  capsule  hy  diapedesis.  or  was  the  capsule  first 
destroyed  as  the  i-esult  of  a  "meltinj:-  away"  of  the  tissney 

in  his  experimental  investigations.  Dentschman  ((pioted  as  above) 
demonstrated  that  a  local  perforation  and  softenin,i|-  of  the  cajtsule  did 
occnr,  and  that  entrance  to  the  pus  cells  was  thus  jiivcn.  and  he  concluded 
that  before  this  occurred  not  a  sin<,de  pus  cell  conld  enter.  tbou«ib  the  len.s 
be  imbedded  in  |)us.  Both  Leber  ^-  and  Wao-enman  ^^  corroborated  these 
investigations.  Leber  states:  "Aside  from  the  larger  holes,  numerous 
microscopical  perforations  are  observed,  in  which  solitary-  or  groups  of  celL 
are  found,  and  between  these  cocci.'"  Wagenman  suggested  that  it  ap- 
])eared  as  though  the  cocci  first  entered  the  capsule,  and  that  the  ])us  cell- 
then  follow^ed.  Otherwise,  he  states,  it  w^ould  be  difficult  to  ex|)lain  whv 
these  perforations  should  occur  in  circumscribed  areas,  rather  than  attack 
the  entire  surface  of  the  ca])sule  to  an  equal  degree.  Thus  there  still  re- 
mained to  be  explained,  what  it  is  that  i)r()duces  this  softening  and  *'melt- 
ing  down"  of  the  ca])sule.  This  Leber  has  done  in  his  exhaustive,  critical 
and  experimental  work.  "Die  Entstehung  der  Kntzundung  und  der 
AVirkung  der  Entzundung  erregenden  Schadlichkeiten,"  Leipsig.  1891;  and 
he  has  made  it  the  subject  oH  s])ecial  observation  and  criticism  in  the  38th 
chapter.  "Purulent  softening  and  'melting  down"  of  tissues."  IJe  states 
(p.  rrl'^)  that  "a  purulent  exudate  free  of  nncrobes  contains  an  niziini 
which  has  a  fluidifying  eflt'ect  on  tibrin.  gellatin  and  dead  animal  tissue: 
that  this  enzym  is  produced  hi/  llir  leucoci/tes,  l)ut  acts  independently  id'  them 
(m  surrounding  tissues.  In  puiulent  inflammations  this  enzi/iii  is  the  prin- 
cipal factor  in  dissolving  tibrin  and  animal  tissues,  and  also  in  pivventing 
the  coagulation  of  fibi-in.  The  prt'vention  of  t'oagulation  is  due  to  the  fact 
tliat  the  fibrinogen  in  the  exudate  or  the  alivady  coagidated  tibi'in  is  con- 
\'.'rted    into   a    non-coagul)le    pepton-like   substance    by    the   action   of   the 


llaKxperiuieiitelle  fntersiiclnniiien  ur  (Jeiiese  der  Erworbeiien  Kapsel  Cat- 
aract.    Inau.u-.  Dissert.  ISTC 

lliBericht  nber  die  XX  Vers,  .roi.th.  (;essel,  ISS'.t.  Zeliender-s  M..  R  1. 
XXYII.  Beila.sh  Heft..  8-45. 

13  "Uber  die  von  Operationsnarbeii  und  Vernarltten  Iris  vorlalleii  aii-elionde 
01asl<ori.er  eiternnj;-."    Von  Craef  .Vnl...   XXXV.  4,  S.  140-144,   tSS<>. 


96 

euzyiii  prodiKi'd  l)y  tln'  pus  cells."  lie  fni'tlici-  cxpicsscs  tlu'  Ix'licf  tliat 
the  solution  of  organic  substances  iakcu  up  in  ilic  cells,  which  Metschiiikoif 
designates  as  intracellular  digestion,  i.v  possibly  due  to  the  action  of  the 
same  enzyni  as  the  above-desci-ibed.  in  the  extracellular  processes  of  solu- 
tion. Leber  uses  the  expression  liisfali/sc  to  designate'  Ibis  purulent  soft- 
ening and  melting  down  of  tissue,  'i'his  he  ascribes  to  cheiincal  changes 
similar  in  tlieii-  action  to  the  pi'ocesses  of  digestion.  The  changes,  he  con- 
tends, are  essentially  chemical  in  their  nature  and  dependent  on  the  action 
of  a  I'crmeiit.  "(hemical.  not  nu'chauical  forces  ha\e  the  power  of  con- 
verting lirm  oiganic-  substances  into  the  fluid  state,  and  the  microscopical 
examination  of  tissues  undergoing  jjurulent  iniilt ration  demonstrates  thac 
its  elenumts  are  undergoing  a  chemical  change."  .Xunu-rous  investigators 
contend  that  the  enzyui  is  ])roduced  by  the  micnj-organisms.  but  Leber 
contends  that  though  the  microbes  may  take  part  in  hastening  the  disin- 
tegration of  tissues,  the  essentially  active  principle  is  derived  from  the 
leucocyte^. 

1'hough  the  suljject  is  not  as  yet  absolutely  settled,  nor  as  yet  fully 
explained,  we  nury  nevertheless  look  u|)on  this  ferment,  this  enzym,  as  the 
essential  factor,  which,  acting  on  the  capsule,  digests  it  and  thiis  prepares 
the  way  for  the  pus  cells  to  gain  entrance  into  the  lens. 

CHAPTER  IV. 

THE  GEXEEAL  PATHOLOGY  AXD  PATH0GE:NES1S  OF  THE 

LEXS. 

I. 

THE  PROGRESSIA^E  GHAXGES  IN  THE  LENS. 

Becker  states,  "In  all  the  non-traumatic  cataracts  which  he  examined 
he  observed  a  new  celluhir  formation,  exceeding  the  normal,  which  was 
derived  from  the  caj^sidar  epithelium."  Exceptionally,  he  observed  this 
condition  in  the  lense>  of  individuals,  which  during  life  had  shown  no 
signs  of  cataract.  If  we  will  now  cojisider  this  as  the  most  important  fact 
so  far  settled,  the  duty  remains  1o  discover  the  cause,  which  incites  this 
hyperplasia  of  capsular  cells  during  Ibe  formation  of  a  cataract.  .\s  we  have 
seen,  this  abnoj'mal  cellular  pi-oduclion  discloses  itself.  Iii-sl.  as  a  hypi'r- 
phasia  of  the  cai)sular  epithelium,  which  is  added  to  the  foi-mation  of  hya- 
line excresejices:  second,  as  a  byper|)hasia  of  the  capsular  epithelium,  lead- 
ing iinally  to  Ihe  formation  of  a  capsular  cataract:  Ihii'd.  in  the  formation 
of  large  vesicular  cells:  fourth,  in  the  formation  of  an  epithelial-like  cover- 


97 

ing  wliich  clothes  the  imicr  .-iirrnrc  of  the  i.oslci-ior  (iiii.-iilc.  All  vjirii'tk-s 
of  new  cellular  t'di'inations  aiv  observed  in  ilie  ditVereiit  i'orius  of  grey  cata- 
ract, though  in  various  degrees  and  under  vaiidiis  eunditions.  ft  is  a 
renin d'ahle  fact,  hoirrrrr.  Iliat  nillirh/  Jijji-rrtil  en  uses  irilliiii  find  milsifJe  of 
the  lens  lead  to  similar  format  Ions. 

1.  CAUSES  OF  TlIK  ABNORMAL  NEW  CELLULAIJ  I'Oh'Al A'JMOXS 
IN  SENILE  CATARAl'T. 

Tu  the  early  chapters  of  this  work,  special  stress  was  laid  on  the 
pressure  which  the  closed  lens  eapsnle  exertg  on  the  form  and  size  of  the 
individual  lens  fibres,  as  well  as  on  the  entire  architecture  of  the  lens.  As 
age  advances,  the  lens  gradually  becomes  more  rigid  and  the  capsule  less 
elastic,  and  in  consequence  of  the  increasing  ]>ressure.  tliis  at  lirst,  impedes 
and  gradually  leads  to  entire  cessation  of  increase  in  its  volume.  After  tlie 
pressure  reaches  a  certain  degree,  the  cells  lose  their  power  of  undergoing 
cell  division. 

The  degree  of  intracapsular  pressure  is  dependent  on  the  relation 
which  two  processes  bear  to  each  other,  during  the  entire  period  of  growth 
of  the  lens.  These  are  the  actual  processes  of  physiological  groirth;  as  seen 
in  the  increase  of  the  capsular  epithelium,  the  formation  of  new  lens  fibres, 
and  the  resulting  increase  of  surface  space  of  the  capsule  and  the  total  in- 
crease in  the  volume  of  the  lens;  and  subsequently  the  physiological  retro- 
gression of  the  lens  fibres^  which  as  soon  as  they  have  reached  the  rays  of 
the  star  figure  of  the  lens  and  have  completed  their  growth,  begin  to 
undergo  retrograde  changes  in  all  three  dimensions.  The  first  process  pro- 
duces an  increase  in  volume,  whereas  the  second  produces  a  reduction  in 
volume.  As  age  advances,  the  phenomena  of  growth  become  less  active, 
whereas  those  of  retrogression  become  more  a])parent.  the  nuire  the  ele 
ments  are  affected.  From  this  it  must  follow,  generally  speaking,  that  a 
period  will  be  reached,  when  both  processes,  relative  to  their  influence  on 
the  lens,  will  be  evenly  balanced. 

Priestly  Smith,  basing  his  statement  on  a  series  of  weighings,  found 
that  under  normal  conditions  this  period  is  only  reached  in  very  advanced 
life.  T^p  to  the  ninetieth  year,  he  always  found  a  number  of  lenses  which 
showed  a  steady  increase  both  in  weight  and  volume.  This  is  in  accord 
with  the  anatomical  examinations,  also  with  the  steady  and  gradual  de- 
crease in  the  ^vidth  of  accommodation.  The  former,  as  well  as  the  latter, 
indicate  that  there  must  be  a  true  balance  between  these  two  antagonistic 
processes,  though  in  fact  this  is  oidy  reached  in  very  extreme  age. 

Priestly  Smith  also  found  a  less  nuud)er  of  senile  lenses,  as  compared 
with  other  lenses  taken  from  individuals  of  the  same  age  which  were  more 


98 

or  less  i-;itai-;u-(()ii>.  or  dilVcrcntly  expressed.  !ie  I'oiiiid  tliat  all  rhiiKhj  Irnaes, 

ercii   lliosr  ir/iicli   irrrc  hiil  /Kiiiidlli/  cIduiIji  Inul  a   red  need  vol  nine. 

After  thai  w  liicdi  has  been  said  in  a  |)re\ioiis  chapter,  ire  enn  on/i/  seek 
for  III  Is  en  use  iif  red  ml  Inn  In  ml  nine  In  I  lie  elieinleni  enndlllnns  nf  Ihe 
n miens  id  llie  enlnrnel  ns  eonijxired  irilli  llinl  nf  Hie  mm-ehindi/  lens. 
(I'a,ux-(i:.) 

The  eapside  and  its  adherent  peripheric  lainelhie  as  fa]-  as  the  ehisticity 
of  the  capsnh'  and  its  connection  witli  the  zoinda  will  peiMnit.  will  foUow 
the  ui'adua)  decreasin<i-  voJiime  of  the  lens.  lUit  this  natni-ally  also  has  its 
limit,  ir  tl)is  is  ont-e  jvacliod.  the  int lacapsnlar  pressure  heiiins  to  fall,  and 
with  this,  one  of  these  c.iuses  whiidi  limited  the  production  of  new  cells 
within  the  ca|)sule  begins  to  he  limited,  and  finally  abolished. 

As  we  have  seen,  Ihere  are  alirni/s  n  nnniber  of  epIfheliaJ  irlls  irlilrli.  nnl- 
irlllislniidl  iKj  llie  eliniujes  nf  iilii/slidni/leni  rel  rni/resslini ,  sllll  relalii 
llieir  rinhlllli/  and  jioieer  nf  prnllfernl Inn. 

Hnl  irllli  llie  rednrlinn  nf  llie  pressure.  Hie  Inirs  nf  fnrninlinn  nrc 
cliunyc'l-  mid  llie  fnrninlire  prnress  heennies  perrerse.  At  the  e(puitor.  con- 
ditions develop  similar  to  those  obsei-ved  subse((uent  to  a  cataract  opera- 
tion, where  the  so-called  "crystalline  pearr'  of  Hommering  develops  in  the 
poc-kets  of  the  capsule.  Here  the  cells  along  the  whorl  increase  in  size, 
forming  large,  irregularly  sha])ed  vesicular  cells.  Along  the  anterior  cap- 
sule, the  new-formed  cells  do  iu>t  push  themselves  in  between  the  older 
and  force  these  more  toward  the  (Mpiator.  l)ut  the  young  cells  are  either 
forced  inward  and  swell  u]).  forming  lai-ge  vesicles,  or  they  undergo  hyper- 
plasia, forming  a  capsular  cataract.  Finally,  after  destroying  the  whorl  and 
loosening  up  the  tibi-es  from  the  posterior  caj^sule.  these  new-formed  celk 
are  pushed  over  the  posterior  capsule,  thus  forming  a  soi-t  of  epithelial 
covering  for  th,.  same  .Xotwithstaiuling  the  gi-eat  morphological  ditl'er- 
ence,  vesicular  cells  may  secondarily  be  developed  from  these  cells;  also 
Irue  capsular  cataracts. 

I>eckei- '  di'ew  attention  to  the  peculiar  cii-cumstance  that  in  the  forma- 
tion of  Sommering's  crystalline  pearl,  the  secnndnri/  enlnrnel  was  formed 
from  tlu'  epithelial  cells  derived  from  the  wlun-l.  These  cells,  after  having 
remainc'd  almost  t(»tally  inactive  for  many  years,  suddeidy  undergo  active 
repi'oduction  again.  One  might  almost  suppose  that  the  impetus  to  the 
i-egeiu'ration  is  due  to  the  enti'ance  of  foi-eign  elenu'uts.  which  gain  en- 
trance aftei'  Ihe  capsule  i>  opened.  The  nbsVnre  nf  prnper  relnllnns  nf 
pressvre.  is  cei'taiidy  one  n\'  ihe  causes  of  ihe  hyperplasia  of  cells  and  the 
formation  of  a  st'condarv  cataract. 


1  "Krystalwulst."    Zehendor's  Klin.  .Mount  shin  tier.  1875.  j).  445. 


99 
The  contents  of  the  lens  capsule  can  never  be  made  up  of  cells  other 
than  epithelial  cells,  except  when  the  capsule  has  been  ruptured. 

Tlie  secondary  cataracts  may  be  divided  into  two  classes:  First,  the 
simple  secondary  cataract,  in  which  the  cataract  is  the  result  of  a  hyper- 
plasia of  the  epithelial  cells  which  line  the  anterior  capsule.  Tliis  is  a  true 
epithelial  structure. 

Second,  the  acute  and  inflammatory  secondary  cataract  is  one,  which, 
per  example,  follows  an  iritis  in  which  anterior  synechia  form,  large  num- 
bers of  leucocytes  are  thrown  out,  fibrin  is  formed  on  the  capsule;  this 
gradually  undergoes  a  formative  process,  and  as  a  result  a  membrane  is 
formed  on  the  external  surface  of  the  anterior  capsule.  This  is  a  con- 
nective tissue  formation. 

2.  THE  CAUSES   OF   THE   XOEMAL  NEW   CELLULAR   FORMA- 
TIONS IN  CONSECUTIVE  CATARACTS. 

As  consecutive  cataract,  we  designate  every  variety  of  cataract  which 
can  be  diagnosticated  both  clinically  and  anatomically  as  a  disease  of  the 
eye,  and  which,  with  a  eertiain  degree  of  regularity,  occurs  as  a  complication 
of  some  general  disease  process  of  the  body,  and  which  has  also  been  shown 
to  occur  as  a  complication  of  disease  in  other  portions  of  the  eye.  Hence 
all  cataracts  occurring  in  both  eyes  of  an  individual  due  to  constitutional 
diseases  (diatheses),  also  all  total  cataracts  due  to  chronic  or  acute  diseases 
of  an  eye,  and  all  partial  cataracts  which  occur  subsequent  to  the  local 
action  of  a  disease  of  the  eye,  belong  to  this  category. 

All  of  these  diseased  conditions  lead  to  an  abnormal  production  of 
cells  inside  of  the  capsule. 

-4.  CONSTITUTIONAL  CATARACT. 
a.  CATARACTA  DIABETICA. 

Of  all  the  cataracts  said  to  follow  a  diathesis,  the  one  said  to  occur 
during  diabetes  mellitus  has  been  most  positively  determined.  By  the 
demonstration  of  the  fact,  that  sugar  is  present  in  the  vitreous  and  in  the 
lens,  the  abnormal  condition  of  the  nutritive  supply  to  the  lens  has  been 
proven.  The  formation  of  the  vesicular  cells  which  have  been  observed 
in  diabetic  cataract  can  only  be  ascribed  to  this  abnormal  nutritive  supply. 
However,  since,  in  all  cases  of  diabetic  cataract,  a  large  increase  in  the 
volume  of  the  lens  has  been  observed  clinically,  and  since  it  has  been 
shown  this  is  due  to  the  taking  up  of  water,  it  would  be  possible  for  this 
unusual  condition  to  lead  to  a  softening  and  swelling  up  of  the  capsule 
and  also  to  a  passing  reduction  of  the  intracapsular  pressure.     We  would 


lOO 

then  have  as  favorable  conditions  for  the  hvperphisia  of  cells,  a  reduction 
of  hindrance  to  growth,  and  an  increased  amount  and  abnormal  constitu- 
tion of  the  nutritive  fluids.  At  the  same  time,  attention  is  drawn  to  the 
fact,  that  a  large  part  of  the  fluid  contained  within  the  capsule  does  not 
enter  with  the  nutritive  supply  in  the  physiological  way,  but  by  diffusion 
through  both  the  anterior  and  posterior  capsule. 

h.  CATAEACTA  CHORIOIDEALIS. 

The  total  cataracts  which  occur  subsequent  to  disease  of  the  posterior 
segment  of  the  eyeball  are  especially  prone,  as  Iwanoff  ^  noted,  to  the 
formation  of  enormous  intracapsular  hyperplasias,  both  in  those  cases  in 
which  the  lens  is  surrounded  by  the  fluid  media,  as  well  as  in  those  in 
which  abnormal  connections  have  been  formed  as  the  result  of  detach- 
ment of  the  retina*,  intraocular  tumors,  cyclitic,  iridocyclitic  or  iritic  bands 
of  new-formed  tssue,  or  as  the  result  of  simple  iritic  adhesions. 

Since  the  final  result  of  all  these  cells  is  the  same  in  all  the  above- 
named  conditions,  it  might  be  correct  to  seek  the  cause  in  a  pathologically 
changed  nutritive  material,  which  is  carried  to  the  lens  and  which  is  the 
real  cause  of  the  hypei-plasia  of  the  cells.  In  cases  of  extensive  adhesions, 
interference  with  the  exchange  and  the  giving  off  of  products  of  decomposi- 
tion must  likewise  be  considered.  Contact  with  the  capsule  may  lead  to 
softening  and  thus  permit  of  an  abnormal  entrance  of  nutritive  fluid,  and 
thus  lead  to  a  hyperplasia  of  the  intracapsular  epithelium.  Often  but  a  few 
days  are  requisite  for  the  entire  posterior  capsule  to  become  covered  on  its 
inner  surface  with  a  layer  of  epithelium. 

c.   CONSECUTIVE  PARTIAL  CATARACT. 
ANTERIOR  POLAR  CATARACT. 

For  the  present  let  us  ignore  the  congenital  forms  of  anterior  axial 
cataract.  In  the  acquired  form  of  anterior  polar  cataract,  the  conditions 
are  such,  that  following  a  perforation  of  the  cornea  and  evacuation  of  the 
aqueous,  the  pupillary  portion  of  the  anterior  capsule  comes  in  contact 
with  the  surface  of  the  ulceration.  A  relatively  short  time  is  sufficient  to 
arouse  the  cells  lying  at  this  point  inside  the  capsule  to  undergo  a  hyper- 
plasia. The  localized  extent  of  this  new  formation  permits  us  to  conclude 
that  this  has  resulted  from  a  localized  cause.  Further,  it  is  certain  that 
at  this  point,  we  are  dealing  with  a  nutritive  flow  which  is  both  abnormal 
in  its  direction,  and  in  its  constitution.    There  can  be  hardly  a  doubt,  but 


2  "Beitrag  zur  Pathologischen  Anatomie  des  Hornhaut  und  Llnsenepithels.' 
Pagensteeher's  Klin.  Beobachtungen.  Bd.  Ill,  p.  12G. 


lOI 

that  the  contact  with  the  pathological  secretion  of  an  ulcer,  softens  th*; 
capsule  in  a  circumscribed  area,  (Muller),  that  it  becomes  less  resistant  and 
places  the  cells  on  its  inner  surface  in  a  condition  of  reduced  pressure. 
The  change  of  form  which  the  capsule  assumes,  in  the  formation  of  a 
cataract  a  pi/ramidaUs  seems  to  be  favorable  to  this  theory.  However,  the 
increased  and  pathological  condition  of  the  nutritive  fluid  will  surely  take 
a  greater  part  in  the  cause  of  this  hyperplasia,  than  the  reduction  of 
tension.  Further,  one  must  not  forget  that  this  form  of  cataract  is  most 
frequently  seen  in  youthful  individuals,  in  whom  undoubtedly  the  cells 
more  easily  divide  and  increase! 

Those  eases  of  pathological  hyperplasia  of  the  intracapsular  cells 
which  develop  after  corneal  ulcers  and  chronic  inflammatory  processes  of 
the  whole  eye,  especially  in  its  posterior  segment,  if  they  lead  to  capsular 
cataracts  which  can  be  diagnosed,  are  known  as  inflammatory,  in 
contradistinction  to  the  non-inflammatory,  which  develop  in  senile  cataract 
during  the  stage  of  over-ripeness.  After  the  identity  of  both  had  been 
anatomically  established,  Becker  attempted  to  characterize  the  hyper- 
plasia, as  the  result  in  part  of  an  "atrophic  hyperplasia"  partly  due  to  an 
increased  nutritive  supply. 

At  the  present  day  we  are  in  a  position  to  recognize  the  fact  that  both 
conditions  are  identical,  though  incited  by  a  variety  of  different  causes.  In 
the  more  restricted  sense,  we  can  not  today  look  upon  the  acquired  anterior 
capsular  cataract  as  an  inflammatory  hyperplasia  or  new  cellular  formation. 
If,  for  clinical  reason,  it  may  appear  desirable  to  retain  the  expression, 
'^inflammatory  capsular  cloudiness,"  or  "inflammatory  capsular  cataract,"  it 
should  only  be  used  in  the  sense,  that  there  are  capsular  cataracts,  the 
formation  of  which  are  due  to  inflammatory  processes  occurring  in  other 
parts  of  the  eye. 

REGENERATIVE  CELLULAR  HYPERPLASIA.  On  page  84,  a 
form  of  capsular  epithelium  was  briefly  referred  to,  which  must  once  more 
be  briefly  reconsidered.  In  the  neighborhood  of  the  hyaline  excresences, 
the  epithelium  almost  invariably  show  a  great  tendency  to  divide  and  in- 
crease. Here  the  principle  of  "atrophic  hyperplasia"  can  not  be  applied, 
because  the  increase  is  confined  to  a  limited  area,  in  the  immediate  neigh- 
borhood of  the  hyaline  excresences.  For  this  very  reason  it  seems  most 
probable  that  this  is  a  regenerative  process.  As  the  result  of  the  colloid 
metamorphosis,  a  part  of  the  epithelium  having  been  lost,  the  effort  to  re- 
produce this,  leads  to  cellular  fission  and  increase.  Another  fact  which 
demands  an  explanation  is  the  localized  growth  of  the  capsular  cataract. 
We  have  seen  that  it  most  frequently  begins  in  the  centre  of  the  anterior 
capsule;  at  times  it  covers  large  surface  areas,  and  in  exceptional  cases  the 


entire  capsule.  Undoubtedly,  this  is  in  some  manner  influenced  by  the 
direction  of  the  stream  of  normal  and  pathological  nutritive  fluid.  Ex- 
ceptionally, the  cai>sule  is  from  1  to  2  mm.  in  thickness,  whereas,  under 
normal  conditions  it  is  not  over  ^  mm.  The  abnormally  large  and  thick 
capsular  cataracts  are  nearly  always  found  in  the  consecutive  and  compli- 
cated cataracts. 

Certain  varieties  of  shrunken  cataracts,  which  appear  to  be  congenital 
or  acquired  during  early  life,  consist  simply  of  a  thickened  capsular  cata- 
ract enclosed  in  a  folded  capsule.  Here  there  has  been  a  very  active  hyper- 
plasia of  the  intracapsular  cells;  the  new  formation  of  cells,  however,  has 
not  been  sufficient  to  fill  the  entire  space  enclosed  by  the  capsule,  but  has 
rather  exhausted  itself  before  going  so  far. 

To  explain  this  fact  one,  might  be  permitted  to  quote  a  remark  made 
by  Ziegler.2  He  draws  attention  to  the  fact  that,  Just  as  in  the  fermenta 
tion  of  alcohol,  the  increase  of  the  yeast  plant  ceases,  when  the  amount  of 
alcohol  has  readied  a  certain  quantity;  similarly,  the  increase  of  both  con- 
nective tissue  and  epithelium  become  restricted  in  their  fomiative  powers 
by  their  own  products.  For  the  former,  it  is  the  formation  of  an  inter- 
cellular substance;  for  the  latter,  it  is  the  intimate  relation,  brought  about 
by  the  cement  substance,  which  restricts  the  further  growth.  Vice  versa. 
the  solution  of  the  intercellular  substance,  and  the  loosening  up  of  the  epi- 
thelium can  again  start  up  this  hyperplasia.  If  we  will  now  apply  this  idea 
to  capsular  cataract,  one  would  say,  that  it  is  the  change  of  tlie  body  of  the 
cell  into  a  dense,  thicl-,  intercellular  substance,  which  there  acts  as  the  limit- 
ing factor.  This  explains  the  reason,  why  it  is  that  we  fail  to  find  the  evi- 
dence of  the  cellular  hyperplasia  which  has  taken  place,  in  fully  formed 
capsular  cataracts  or  in  the  congenital  membranous  cataracts.  In  this  is 
also  to  be  found  the  reason,  that  one  never  finds  a  hyperplasia  of  cells  which 
becomes  greater  than  the  size  of  the  lens,  and  why  it  is  that  there  are  no  tumors 
of  the  lens. 

II. 

KETR0GKES8IVE  CHANGES. 

a. 
THE  LENS  FIBRES.  While  studying  the  sclerosis  of  the  lens  and 
the  formation  of  a  nucleus,  we  noted  changes  which  we  designated  as  those 
of  simple  atrophy.  Owing  to  the  present  state  of  our  knowledge,  the 
chemical  changes,  which  take  place  in  the  lamella  which  surround  the 
nucleus,  are  not  definitely  known.     The  most  we  can  say  is,  that  this  is 

3  Lehrbuch  der  Aljiemeinen  uud  Speciollfii  ratli.    Aii:i(.  mid  Pathogonose, 
1882,  2  Auft,  1  Thlel,  p.  124. 


I03 
partly  a  Tatty  nictamorphosis,  iiia-;miicli  as  oliolcstcriiic  and  inargarin  (?) 
crystals  are  found. 

Knies  described  this  cataractoiis  disintooration  of  the  lens  fibres,  as 
changes  which  he  comi)ares  to  those  of  so-called  "cloudy  swelling.'" 
(Virchow).  Becker  points  to  the  fact  that  even  Knies  drew  attention  to 
the  fact,  that  nothing  positive  is  known  concerning  the  resorption  of 
albuminous  cloudy  lens  fibres  and  the  coincident  clearing  up  of  the  cloudi- 
ness. ]jikewise,  the  idea  that  the  formation  of  a  cataract  is  a  parenchy- 
matous inflammatory  process  can  not  be  looked  upon  as  a  "•ha|)py  thought," 
since,  in  order  to  prove  this,  its  nourishing  vessels  would  of  necessity  be 
involved,  an  experiment  which  even  Knies  admits  he  could  nut  carry  out. 


As  we  have  seen^  the  inlracapsular  cells  may  show  signs  which  can  be 
ascribed  to  atrophy.  An  almost  constant  accompaniment  of  the  over-ripe 
senile  cataracts,  is  the  change  in  the  nuclei  of  the  cells  which  have  been 
designated  as  the  products  of  colloid  metamorphosis.  Finally,  the  so-called 
vesicular  cells  which  develop  both  from  the  preformed  epithelium  of  the 
posterior  capsule,  are  in  all  probability  to  be  looked  upon  as  Injdropsical 
cells. 

All  cells  which  are  found  within  an  uninjured  capsule,  both  the  cells 
which  are  normally  present  on  the  anterior  capsule,  more  especially  all 
new-formed  cells,  possess  to  a  high  degree,  the  common  tendency  of  under- 
going soon  and  quickly  retrogressive  change.  Thus  one  constantly  finds 
in  the  tissue  of  a  capsular  cataract  a  portion  of  the  cells  from  which  the 
structure  is  formed,  imbedded  in  a  colloid  mass.  Finally,  a  deposit  of  lime 
salts  is  at  times  found  in  the  tissue  of  a  capsular  cataract,  which  is  known 
as  a  petrifaction,  a  condition  similarly  noted  in  other  tissues. 

All  the  assumptions,  excepting  possibly  the  last,  are  wanting  in  chem- 
ical proof.  Thus  it  still  remains  an  open  question  whether  this  is  really  a 
colloid  metamorphosis  or  a  hyaline  degeneration. 

IWii.  assuming  that  our  assum])tions  are  true,  it  certainly  nnist  seem 
astounding,  that  such  a  variety  of  "known  changes,  both  progressive  and 
retrogressive,  can  take  place  within  an  uninjured  closed  capsule.  But  only 
as  long  as  one  fails  to  recognize  the  fact,  that  all  these  processes  are  likewise 
observed  in  other  epithelial  structures,  as  the  resuH  of  a  disturbed  nutrition, 
hence  one  would  expect,  since  the  lens  is  a  pure  epithelial  structure  to 
find  them  here  with  a  certain  degree  of  regularity. 


PART  III. 

ANOMALIES  OF  TKANSPARENCY. 

In  the  following  section  the  various  forms  of  cloudiness  of  the  lens 
will  be  considered.  Since  departures  from  the  normal,  both  in  size  and 
form  of  the  lens,  occur  but  seldom  congenitally,  whereas,  when  acquired, 
are  always  accompanied  by  cloudiness  of  the  substance  of  the  lens,  hence 
it  will  be  unnecessary  to  devote  a  special  section  to  their  consideration, 
but  they  will  be  considered  together  with  the  opacities  of  the  lens. 

CHAPTER  I. 

THE  GEEY  CATARACT. 

DEFINITION.  Every  opacity  of  the  lens  system  is  called  a  grey 
cataract  or  "staar.''^ 

SYNONYMS.  Glaucoma,  glaucosis,  glaucosies;  hypochyma,  hypo- 
chysis;  suffusio,  s.  aquae,  aquae  descensus;  catarrhacta,  cataracta;  cataracte; 
cataract;  cataratta,  star  or  staar. 

"The  expressions,  'staar'  and  'cataract'  were  in  common  use  at  the 
time  Brisseau  and  Maitre  Jean  conclusively  proved,  that  the  cause  of  the 
interference  with  sight,  which  for  hundreds  of  years  previously  had  been 
removed  by  depression,  was  not  due  to  a  new-formed  membrane  in  the 
pupil,  which  the  cataract  was  supposed  to  be,  but  that  it  was  due  to  a 
cloudiness  of  the  lens.  Although  in  ancient  times  a  diseased  cloudiness 
of  the  lens  had  been  known,  and  called  glaucoma,  one  was  nevertheless 
justified  in  retaining  the  name  'cataract'  for  the  new  conception  of  the 
disease,  as  the  possibiUty  of  restoring  vision  by  operative  interference  still 
remained  as  a  mark  of  difference  between  glaucoma  and  cataract." 

"The  arguments  used  against  Brisseau  by  the  French  Academy  were 
essentially  those  of  Galen.  The  latter's  medical  knowledge,  however,  was 
but  that,  as  it  had  been  developed  since  the  time  of  Hippocrates." 

"In  Greek  literature  are  found  the  following  expressions:  yXavxc^ff'^^ 
(yXavxf^(^i^)  0^  yXavxx^^^  ^^^  vTToxvjua  or  V7r6xv(^i'>.  ^^ 
these  expressions,  the  Latin  writers  only  retained  glaucoma;  they  trans- 
lated, however,  vttoxvGi?  as  'suffusio/" 

1  There  is  no  English  translation  for  the  word  Staar  other  than  Cataract. 
Its  derivation  will  be  considered  further  on. 


I05 
''It  is  diftieult  to  determine  at  the  present  day,  which  I'oftiis  of  disease 
the  ancients  designated  by  these  names,  owing  to  their  great  lack  of  ana- 
tomical knowledge  and  sufficiently  accurate  methods  of  examination,  which 
but  in  recent  years  have  been  perfected  to  such  a  degree  as  to  admit  of  a 
proper  understanding  of  the  various  forms  of  this  disease.-  It  is  very  prob- 
able, however,  that  every  disease  leading  to  a  discoloration  of  the  {)upil  re- 
ceived the  same  name,  at  one  time  being  designated  as  glaucoma,  at  anothei' 
as  hi/pochi/sis.  Then  difl'erentiations  began  to  be  made,  but  having  no 
accurate  anatomical  basis,  were  but  poorly  kept  apart.  Gradually  they 
became  accustomed  to  speak  of  'suffusio'  where  an  iritis,  pupillary  mem- 
brane and  primary  cloudiness  of  the  lens  existed,  which,  however,  w-as 
looked  upon  as  a  new-formed  memhrane,  but  they  designated  every  con- 
ceivable form  of  complicated  cataract  as  glaucoma,  aside  from  the  dis- 
ease, glaucoma,  as  we  understand  it  today." 

"The  only  expression  known  to  Hippocrates  was  yXavxoJ(^t£''.  This 
is  evident  from  Aphorism,  XXXI. ,  3,  in  which  he  enumerates  the  diseases  of 
the  aged,  and  uses  the  word  yXavxcoffte?  to  designate  cataract,  and  with 
the  occurrence  of  which  he  must  have  been  very  familiar.  Celsius,  how- 
ever, quite  contrary  to  the  above,  uses  the  word  "svffusio,'  and  thus  shows 
that  he  located  the  disease  in  a  place  other  than  in  the  lens:  rather  in  front 
of  it,  'qua  parte  pupilla  est,  locus  vacuus  est.'^  At  the  same  time,  Plinius 
used  both  expressions  successively  without  defining  them.  He,  however, 
suggesti?,  from  his  very  rich  therapeutic  treasures,  different  remedies  for 
each,  so  that  one  is  led  to  believe  that  he  looked  upon  them  as  two  separate 
and  distinct  diseases.*  Oribasius  has  saved  for  us,  the  opinion  of  Kufus, 
who  lived  some  time  after  Plinius:  'Glaucoma  humoris  glacialis,  i.  e.  crystal- 
lini  qui  ex  proprio  colore  in  glaucum  convertatur  et  mutetur,  morbum  esse 
putavertunt,  suffusionem  vero  esse  effusionem  humorum  inter  uveam  et 
crystalloidem  tunieam  concrementium,'  and  he  adds,  that  all  cases  of 
glaucoma  are  incurable,  but  that  vTToxvjua  is;  but  strictly  speaking,  not 
every  case.^  We  find  that  Galen  expressed  the  same  opinion.  According  to 
Kuhn's  translation,^  Galen  says,  'Suffusio  est  concretio  aquosi  humoris  quae 
visum  magis  minusve  imi)edit.  Diflt'ert  suffusio  a  glaucomate  tum  quod 
suffusio  concretio  sil  dilute  humoris,  glaucoma  vero  naturalium  mutatio 
humorum  in  caesium  colorem,  tum  quod  glaucomate  baud  prorsus  in  suf- 
fusione  aliquantuhim  cernant.'  " 

2  Von  Graefe  Glaucoma.  1858. 

3  Lib.  VII.  cap.  7.  18. 

4  His.  Nat.  XXVIII,  8:  XXIV.  (J;  and  XXXII.  4. 

5  Morgagni,  I.  e.  Synops.  Libr.  VIII.  ca{>.  47.  p.  1.30.  ed.  Stephen. 

6  Vol.  XIX,  S.  f.  Med.  303  Lips.  1830.  p.  4:JS. 


io6 

"One  may  .«ay.  that  these  words  give  a  comprehensive  account  of  the 
knowledge  which  the  medical  world  possessed  on  the  subject  up  to  the 
beginning  of  the  eighteenth  century." 

"According  to  the  Latin  translation  by  Emerius.  the  teaching  of  the 
physician  and  philosopher,  Leo,  who  lived  about  800  B.  C,  (p.  146),  reads 
39  follows:  'Suffusio  (vTToxvOt?)  est  cum  inter  membranum  uviformam 
et  corneam  humor  pituitosus  et  crassus  quasi  returbidus  coagulatus  est  et 
pupillam  obfuscat  nee  semere  sinit:  qui  hoc  morbo  laborant  initio  culices 
vident.  Curator  vero  punctione,  non  principio  sed  postquam  aliquamdiu 
perstiterit.'  A  few  lines  below  he  says:  'Glaucosis  est  ubi  crystallinus  humor 
veluti  coagulatus  est  et  albidior  f actus  et  visum  impedit:  fit  autem  semper 
in  senibus  malumque  sanari  nequit.'  " 

'•'About  the  year  1150,  the  Salernian  Physician  Matteus  Platearius 
speaks  of  cataract  as  one  of  the  diseases  of  the  eye,  and  defines  it  as  fol- 
lows: 'Cataracte  visus  inter  conjunetivam  et  corneam  tunica  nascuntur  et 
uveam  tunicam  subalbidam  reddunt.'  Four  hundred  years  later,  we  find 
the  celebrated  Ambrose  Pare,  the  first  physician  who  wrote  in  French, 
speaking  of  a  'suffusio,'  'cataraeta'  or  'coulisse,'  a  'concretion  d'humeur' 
placed  between  cornea  and  lens;  and  this,  along  wdth  glaucoma,  hetero- 
glautis,  leucoma,  aygrias  and  acatastasia  crystalloidous;  the  last  of  these 
was  already  being. spoken  of  as  a  luxation  of  the  lens." 

"Not  that  during  all  these  years  the  correct  view  had  not  time  and  again 
been  expounded.  In  1673  Werner  Wolfing  of  Hamburg,  Professor  at 
Jena,'^  is  said  to  have  shown  that  the  cloudiness  in  the  pupil,  which  is 
amenable  to  operative  interference,  has  its  seat  in  the  lens.  In  Gassendi  ^ 
one  finds  the  following:  'Since  Lasnier^  has  shown  that  an  animal  without 
a  lens  can  see,  it  is  not  necessary  to  seek  for  further  proof  to  demonstrate 
that  the  power  of  vision  does  not  depend  on  the  lens.'  He  has  shown  that 
the  cataract  is  not  a  membrane  between  uvea  and  lens,  which  can  be  torn 
away  mth  a  needle  and  depressed  into  the  depths  of  the  eye,  but  that  it  is 
the  crystalline  body  itself,  which  is  shrunken,  is  separated  from  the  ciliar\'' 
processes,  and  is  depressed  into  the  vitreous.  The  celebrated  Franz  Quarre, 
as  Morgagni  tried  to  prove,  expressed  the  same  opinion  even  before  Lasnier. 
The  great  physist,  Mariotte;!^  also  Jacques  Kohault  ^^  and  Borrelll  12  were 
of  the  same  opinion  as  the  above-named  investigators.    Eohault  says:  "Que 

7  Dissert  Anat.  Lib.,  b.  c,  p.  73. 

8  Physic  III,  Lib.  7,  D.  B.,  1G60. 
9Remy  D.    Paris,  1650. 

10  Nouvelles  decouvertes  touchant  la  vue  Paris.  1668. 

11  Tractus  Physics  I,  cap.  35. 

12  Historiore  et  observations  medico-physicae,  IV,  Paris,  1657. 


I07 
la  cataracta  n'est  pas  une  taye  qui  se  fonne  del  humeur  cristalline,  comme 
on  la  cm  long  temps,  mais  bien  une  alteration  de  cette  humeur  me  me  qui 
a  enteirement  perdu  sa  transparonco.'  According  to  Heister,  in  1707  the  great 
Boerhaven  taught  the  same  idea  in  his  clinic,  before  he  had  read  the  ^Y^it- 
ings  of  Brisseau  and  Meister  Antonius,  but  these  few  voices  were  but  little 
heeded  by  their  contemporaries.  To  the  two  last-mentioned  gentlemen 
fell  the  task  of  overcoming  the  opposition  of  the  Paris  Academy  of  Medi- 
cine, and  of  gradually  introducing  to  the  incdical  profession  at  large  the 
correct  solution  of  this  question." 

"On  the  6th  of  April,  1705,  in  the  hospital  at  Doorniek,  Brisseau 
operated  on  the  eye  of  a  soldier  who  had  died  of  the  flux,  and  who  had  a 
simple  ripe  cataract.  He  made  a  depression,  and  after  he  had  removed 
the  membrane,  which  he  held  it  to  be,  and  the  pupil  was  black  again,  he 
dissected  the  eye,  and  found  that  the  opaque  lens  was  not  in  its  proper 
position,  but  that  it  was  depressed  into  the  vitreous.  On  the  17th  of  No- 
vember of  the  same  year,  he  reported  his  observation  to  the  Academy.  The 
Academy,  however,  totally  ignored  his  announcement,  and  one  of  the  mem- 
bers— Duverney — advised  him  to  keep  his  discovery  to  himself,  and  not  to 
make  himself  the  laughing-stock  of  the  Academy.  Brisseau's  silent  resolve 
was,  further  investigation,  on  which  to  base  his  opinion.  In  1707  he  op- 
erated a  hard  cataract;  this  split  into  pieces,  and  thus  he  was  convinced 
that  it  could  not  be  a  membrane,  but  must  have  its  seat  in  the  lens. 

"Maitre  Jean  ^^  tells  us  that  he  had  arrived  at  the  same  conclusion  as 
early  as  1682.  Later  on.  he  examined  the  eyes  of  a  corpse,  which  were  cat- 
aractous,  and  saw  plainly  that  the  cloudiness  was  in  the  lens." 

"One  of  the  greatest  learned  men  of  his  time,  who  took  up  the  new 
teaching  in  a  positive  manner,  and  who  with  untiring  efforts  defended  it 
against  many  disbelievers,  even  after  the  French  Academy  had  given  in, 
was  Prof.  Lorenz  Heister,  Professor  at  Altdorf  and  Helmstedt.  In  his 
'Tractus  de  Cataracta  glaucomate  et  amaurosi,'  Altdorf,  1812,  he  writes, 
"duo  industrii  galii  post  multa  experimenta  sedem  cataractae  exhumore 
aqueo  penitus  in  humorem  crystallinum  transtulerunt.^  " 

"The  discussions  of  the  French  Academy  from  1705  to  1708,  caused  by 
Brisseau  and  Maitre  Jean,  show  the  views  of  the  corporate  body  of  medi- 
cine of  that  time.  At  that  time,  cataract  was  held  to  be  a  small,  somewhat 
thickened  membrane  situated  in  the  pupil,  and  which  had  formed  in  the 
aqueous  humour,  and  which  could,  by  means  of  a  needle,  be  successfully 
rolled  up  and  depressed  into  the  deptlis  of  the  eye.  Even  at  that  time,  glau- 
coma was  held  to  be  an  opacity  of  the  lens,  said  to  be  incurable,  in  contra- 

13  Traite  des  Maladies  de  I'oell  Troyes.  1707. 


io8 

distinction  to  cataract.  At  first  the  Acadeni}"  took  a  stand  on  the  authority 
of  Galen,  then  again  it  held  an  opposite  view,  that  an  eye  without  a  lens 
could  not  see;  then  they  permitted  Littre  to  appear  before  the  Academy 
and  demonstrate  an  iritic  memhrane  as  a  true  cataract.  Finally,  however, 
it  entered  upon  the  road  of  investigation  itself,  in  that  the  Academy  had 
eyes  dissected  before  it,  which  had  been  operated  on  for  cataract  by  Mery. 
Naturally,  since  it  was  impossible  to  be  otherwise,  these  investigations 
finally  demonstrated  the  truth  of  the  fact  which  had  been  so  hotly  con- 
tested. In  the  year  1808,  the  Academy  began  its  acknowledgement  with 
the  following  memorable  words: 

"La  verite  coiumeuee  a  se  deeouvrir  sur  la  question  des  Cataractes,"  and  a 
few  lines  further  down  continues:  "M.  Brisseau,  medeein  de  Touruai  et  M. 
Antoine,  tons  deux  inventeurs  en  nieme  temps  ou  plutot  restaurateurs,  sans  le 
scavoir,  du  nouveau  sisteme  de  feu  M.  Rohault,  qui  confondoit  le  Glaucoma  et 
la  Cataracte.  soutenoient  et  par  uns  suite  de  ce  sisteme  el  par  des  experiences 
dont  ils  etaient  convaincus,  que  Ton  pent  voir  sans  cristallin,  c'est  a  dire,  sans 
ce  qui  a  toujours  passe  pour  le  principal  instrument  de  la  vision.  Quelque 
etrange  que  soit  ce  Paradoxe.  I'Academie  en  avoit  des  I'annee  precedente  ap- 
percu  la  possibilite,  mais  enlin  il  est  devenu  un  fait  constant  I'Academie  a  vu 
>un  Cristallin  que  Ion  avoit  tire  a  un  Pretre  en  presence  de  Mery  et  elle  a  vu 
ce  meme  Pretre  lire  du  meme  oeil  avec  une  forte  loupe  ces  gros  Cataractes,  que 
les  Imprimeurs  appellent  Parangon."  14 

"The  proceedings  of  the  Academy  during  the  years  1705-1708  are  in 
other  respects  very  important  to  opthalmology.  They  contain  the  views, 
concerning  the  new  teachings,  contained  in  a  series  of  optical  studies  by 
De  la  Hire,  father  and  son,  by  whom  it  was  shown  that  the  aqueous  and 
vitreous  humour  have  the  same  index  of  refraction,  and  in  which  for  the 
first  time  the  dioptric  conditions  of  the  aphakic  eye  were  properly  pre- 
sented." 

"Though  the  new  ideas  were  accepted  by  the  Academy  in  the  most 
enthusiastic  manner  and  were  taken  up  by  the  learned  world  of  France  and 
the  neighboring  countries,  those  were  not  wanting  who  violently  opposed 
them.  The  most  stubborn  opponent  was  Woolhouse,  an  English  physician 
resident  in  Paris.  The  many  discussions  between  him  and  Heister  are, 
even  at  the  present  day.  worthy  of  being  read.  Later  on,  the  conception 
of  cataract  was  changed  by  Gunz,  (Schnitzlein,  praes  Gunz,  diss  de  suffus- 
sionis  natura  et  curatione),  who  describes  as  cataract  every  dark  body 
situated  between  cornea  and  vitreous,  which  impeded  vision,  or  it  was  said 
that  cataract  was  eveiy  cloudiness  between  cornea  and  vitreous,  (Macken- 

14  Hist,  de  TAcad.  Royale  des  Sciences.  Annee,  1708.  p.  39. 


I09 
zie),  until  finally  Vclpeau  ^■''  defined  cataract  as  "une  opacite  centre  nature 
dun  des  millieux  tran.sparencs  de  I'oeil,  (pie  tiaversent  habiluellement  des 
rayons  lumineux  pour  arriver  a  la  retine.'  Other  authoritis,  like  Wardrop, 
went  a  step  further  and  defined  every  perceptible  disease  in  the  pupil  which 
disturbed  vision  as  a  cataract,  and  used  as  synonyms  the  following  ex- 
pressions: Cataracla  nigra,  guff  a  serena,  black  cataract  and  amaurosis." 

''Beyond  all  doubt,  the  word  'cataracta'  is  of  Greek  origin, 
xaTapprjyv/xi[HaTappa.GGOL>)^  and  hence  was  often  written 'catarrhacta.' 
It  was  never  used  by  the  ancients  to  describe  a  disease  of  the  eye.  The  first 
time  it  is  found  used  in  the  literature  of  this  subject,  is  in  the  above  given 
definition  by  the  Salernian  physician,  Platerius,  1150,^^  and  here  it  is  used 
to  express  the  same  idea  as  suffusio  or  hypochysis.  In  Mackenzie's  work,^^ 
the  opinion  is  expressed  that  ,tlie  Arabs — who,  as  is  well  known,  in  scien- 
tific aft'airs,  especially  medical,  depended  entirely  on  the  teachings  of  Galen 
— found  this  expression,  L';ro;j;f(TzS',  and  translated  it  literally,  and  then 
later  on,  when  the  Salernian  translated  the  works  of  iVlbulcasis  and 
Avicenna  into  Latin,  this  expression,  which  had  come  into  general  use,  was 
retained,  and  thus  the  neiv  word  "cataract'  was  coined.  In  the  translation 
of  Albulcasis  by  Gerard  de  Cremona,  (1114),  the  subject  of  the  twenty-third 
chapter  reads,  'De  cura  aquae  quae  descendit  in  oculo  vel  cataracta.'  The 
time  when  the  passage  was  written  corresponds  about  to  the  time  of 
Platearius,  and  the  original  sense  in  which  the  word  'cataract'  wa^  used 
was  to  convey  the  idea  of  'a  flowing  down  of  water,'  'a  water  fall.'  As  a 
matter  of  fact,  in  Avicenna,^^  the  Arabic  expression  given  for  grey  cataract 
is  'nuzul  el  ma,'  which,  literally  translated,  also  means,  'a  flowing  down  of 
water.'  There  can,  therefore,  be  no  doubt  but  that  Mackenzie's  idea  is  the 
correct  one.  This  is  all  the  more  striking,  since  the  literal  meaning  of  the 
word,  used  to  designate  the  grey  cataract  became  the  accepted  view  of  the 
nature  of  the  disease  by  later  authorities.  Thus,  x\mbrose  Parre,  (bom  in 
1517),  translating  the  word  'cataract'  into  French,  uses  the  word  'coulisse/ 
or  'curtain,'  and.  he  declares,  'C'est  en  effet  du  sens  de  cloture  de  coulisse  qui 
ferme,  que  la  mot  cataracte  a  passe  au  sens  d'opacite  du  cristallin.'  Antonie 
Furetiere  (1690)  gives  the  same  definition  in  his  'Dictionaire  Universal;' 
he  however  quotes  Parre.  This  proof  is  all  the  more  important,  since  Parre 
was  looked  upon  as  the  first  doctor  who  wrote  in  French.  Only  after  the 
decree  of  King  Francis  I.,  1523  and  1529,  and  the  edicts  of  Villers-Cot- 


isClinique  Chirurg.,  1840,  p.  517. 

16  Hirsch  Klin.  Monatsblatter.  1S<!0,  p.  284.   Practica.  I.  II  and  VII.  ed.  Lugd. 
Bat.,  1525,  fol.  2.39.    DiRieuzi  Collect  Salernit  Napoli.  1853.  Tom.  II.  p.  146. 

17  Ed.  von  Warlomont  und  Testclin.  II.  p.  3W>. 

18  Lib.  Ill,  Faun  III,  Tract  IV,  Cap.  18. 


no 


terets  (1539)  was  the  court,  compelled  to  carry  on  its  proceedings  in  the 
French  language.  As  is  well  known,  Calvin  originally  wrote  his  'Insti- 
tutio  religionio  Christianae'  in  Latin;  and  first  in  1536,  when  filled  witli 
hatred  against  the  language  of  the  Pope  and  its  traditions,  and  when  he 
found  himself  compelled  to  turn  to  the  people,  he  concluded  to  translate 
his  principal  work  into  his  native  tongue.  As  a  like  proceeding  does  not 
occur  in  all  scientific  writings  up  to  this  time,  Ambrose  PaiTe,  who  wrote 
in  the  forties  of  the  sixteenth  century,  is  therefore  to  be  presumed  was  the 
first  to  have  the  written,  'catarada,'  as  a  French  word.  So  far  had  the 
etymology  of  the  word  been  lost,  that  the  Academy,  in  its  discussions  with 
Brisseau,  did  not  hesitate  to  state  as  a  fact,  that  the  word  'cataract'  meant 
a  membrane  before  the  pupil,  and  used  this  as  an  argument  against  the 
new  teaching.  'Les  cataractes  des  yeux  ont  este  ainsi  appellees  dun  mot 
Grec  qui  signifie  une  Porte  gu'on  laisse  tomber  de  haut  en  has  comme  une 
Sarrasine,  el  en  efi'et  ce  sont  des  especes  de  Ports,  gui  ferment  I'oeil  aux 
rayons  de  la  lumiere.^^  To  quote  but  a  single  passage  from  the  literature 
of  foreign  countries,  taken  from  the  writings  of  Laurentius  Heisterus,  (31, 
p  1),  'Vulgo  autem  el  notiori  inter  medicos  vocabule  ratarada  vocatur, 
quae  vox,  teste  Livio  (XXVII.,  28)  portas  pendulas  et  recidentes,  quae  ad 
ingressum  urbium,  praecipue  munitarum,  conspiciunter,  significat,  quibus 
recidentibus  vel  demissis  liber  prohibetur  transitus  et  vernaculo  sermone 
Fall  Gattern  appellantur.  N"otat  etiam  cataract  a  pessulum  vel  obicem,  quo 
porta  obfirmi  solet.  Belgae  quoque  cataractas  vocant  robustissimas  illas 
valvas,  quibus  aquarum  iiTuentium  vim  cohibent,  ne  plus,  quam  par  est, 
aquae  in  oppida  veb  campos  influat,  et  ab  iis  vernacula  sua  Slui/sen  nonima- 
tur.'  " 

'It  is  evident  that  this  erroneous  idea  was  evolved  after  the  word 
'catai-act'  had  come  into  use,  and  the  historical  development  of  the  word 
had  been  entirely  forgotten.  The  true  meaning  of  the  word  'trap- 
door' or  'sluiceway,'  as  used  by  the  ancients,  had  become  entirely  changed 
to  that  of  a  waterfall,  this  coinciding  more  nearly  with  the  prevailing  idea 
as  to  the  anatomical  conditions  of  a  cataract." 

"The  German  word  'staar,'  likewise  the  compound  word  'staar-blind,' 
are  very  old.  In  the  Keronishe  Glossen  of  the  eighth  century  one  finds  the 
following:  'Hyerna  bestia  staraplint  (Reichenauer  Ausgabe;  hyaena  stara 
bestia  plint)  cujus  pupillae  lapideae  sunt  des  seha  augono  stani  sint.'  This 
passage  is  copied  in   Graft's  Diutiska,  I.,   339.20     Weigand  21   says,   'AI3 

19  Hist.  <1<'1   A<:i(l.   K<..v  (les  Sc.    17<»;.   p.    12. 

20  See  also  Crnffs  AIUkk-Ii   1  >rulsclier  Spr:iclis<-li:it/.   Ml.  S..  -Jii:'.. 

21  Deutsclits  Woitcil.uili.   II.  S..  TT'.t. 


Ill 

Wurzelvorbuin  i.st  aufziistelleii  ein  gotli.  stairan,  ahd,  stoian  unbeweglich 
stelien,  woven  ahd,  staren,  mhd,  stem  =  die  Augen  unbeweglich  auf 
etwas  richtet,  starren.'  Therefore,  'staar'  signifies,  a  staring  look.  I  have 
not  been  able  to  discover,  where  it  was  that  the  word  first  came  into  use." 

"Since  the  word  'staar'  was  originally  used  to  denote  a  symptom  of  an 
eye  disease,  namely,  the  staring  look,  one  can  easily  see  how  gradually  it 
began  to  be  used  to  designate  various  diseases  of  the  eye.  As  we  began  to 
discern  differences,  it  began  to  be  used  in  connection  with  other  words  to 
designate  the  variety  as  the  grey,  the  black,  etc.,  and  these  expressions  are 
in  use  at  the  present  day.  They  were,  however,  in  former  times  a  great 
variety  of  other  forms  in  use,  which  have  since  been  set  aside.  Thus 
George  Bartisch  of  Kocnigsbruck,  citizen,  oculist  and  Surgeon  to  the 
King's  City  of  Dresden,  in  his  work  on  opthalmology,  published  in  1583, 
speaks  of  the  green,  the  white,  the  yellow  and  the  blue  'staar.'  At  the  pres- 
ent day  the  word  'staar'  used  alone,  without  the  prefix  'grey,'  will  be 
synonymous  with  cataract,  meaning  a  cloudiness  of  the  lens. 

''The  knowledge  of  the  original  meaning  of  the  word,  seems  grad- 
ually to  have  been  lost,  both  by  the  physician  and  the  general  public.  This 
very  same  Bartisch  writes,  (1.  c,  p.  42),  'I  have  not  been  able  to  discover, 
why  this  is  called  "staar,"  or  where  the  word  originated.  The  word  is  so 
well  known  and  in  such  common  use,  that  it  is  equally  often  used  by 
citizen  or  farmer,  the  educated  or  ignorant.  For  whether  they  speak  of, 
see,  or  hear  of  a  blind  person,  they  know  of  nothing  further  to  say  than 
that  it  must  be  a  "staar,"  and  they  say  — "he  is  staar-hlind."  '  In  his  very 
next  statement,  however,  he  says,  "that  it  is  no  wonder  that  the  word 
"staar"  has  been  used  to  designate  a  disease  of  the  eye,  since  there  are 
other  infirmities,  defects,  and  ills  of  man  which  have  been  named  after 
anianals  and  other  things,  such  as  krebs,  lupus,  carfunkel  and  ranula."  On 
the  next  page,  he  goes  on  to  state,  that  there  are  people  who  imagine  that 
this  defect  is  due  to  the  starling,  a  bird,  for  if  we  eat  it  frequently,  or 
drink  from  the  same  water  of  which  the  bird  has  partaken,  or  in  which 
it  has  taken  a  bath,  (we  become  staar-bHnd)(?)  This,  however,  is  a 
superstition  and  a  false  delusion.  Luther  spelled  the  word  'starr';  Bartisch, 
as  we  have  seen,  'star.'  In  Andersen,-^  I  find,  'Im  mhd  bedeutet  star,  also 
subst  sturnus,  als  adj  rigidus,  di  nach  gewohnlicher  Schreibweise  im  mhd 
staar  uud  starr.  Seit  dem  aber  das  ahd  staraplint  statt  durch  starr-blind, 
wie  es  hatte  lauten  sollon  (vgl  austarren,  stieren)  viel  mehr  durch  staar- 
blind  weidergegeben  wurde  und  ein  subst,  staar  (augenstarre  hin  zugetreten 
ist,  gerieth  man  spater  auf  dem  gedanken  den    vogelnahmen    stahr    zu 


22  Deutsche  Orthographie,  S..  p.  18. 


112 

schrieben.  Leicht  ist  es  einziisehen,  class,  wofern  nieht,  was  unstreitig 
das  einfachste  ware,  die  mhd,  form  fur  beide  worter  verbleiben  kann, 
mindestens  das  eine  der  verbaldehung  lieber  eintriethe,  weil  da  durch  der 
zusammenhang  mit  starr  desto  deutlicher  hervortrete.'  This  also  answers 
Strieker's  question  (Star  or  starr ?).23  The  work  of  Lichtman  mentioned 
by  him  (Nuremburg,  1720),  contains  the  above-given  passage  of  Bartisch." 

"Later  on,  the  word  'staar,'  was  used  with  an  entirely  different  mean- 
ing, (though  seldom  so  applied),  to  signify  the  pupil  ('augenstern'),  as  per 
example,  by  Baggensen  and  Matthison.  The  word  'augenstern'  could  be 
used  to  signify  a  pupil  containing  a  'star,"  or  cataractous  formation,  but 
not  in  the  opposite  sense.  Though  one  does  meet  with  the  expression 
in  Rabener's  work,  (IV.,  36),  'I  have  a  star  (stern — a  star  in  the  firma- 
ment) on  the  one  eye,"  this  does  not  give  us  a  clue  to  the  derivation  of  the 
word,  nor  is  this  suggestive  that  the  word  is  derived  from  'stern,'  (a  star  in 
the  firmament),  or  even  derived  from  the  English  word  'star,'  (a  deriva- 
tion which  has  been  hinted  at).  Opposed  to  all  this,  is  the  fact  that  the 
English,  as  well  as  the  French  and  Italians,  have  for  a  long  time  never 
used  any  other  term  for  'staar'  than  ^cataract.' 

CATAEACTA  VERA  AND  SPURIA.  Several  authors  differentiate 
between  true  and  false  cataracts.  In  eataracta  spuria  we  find  a  deposit  on 
the  anterior  surface  of  the  anterior  capsule,  be  this  a  pigmented  exudate 
following  an  iritis,  or  an  organized  tissue,  the  result  of  an  inflammatory 
deposit.  (See  page  99).  After  a  corneal  perforation,  if  the  lens  comes 
in  contact  with  the  corneal  surface,  and  subsequently  on  closure  of  the 
perforation,  the  lens  on  returning  to  its  normal  position,  may  take  with  it 
some  of  the  cicatrical  tissue  adherent  to  the  anterior  capsule,  eataracta  cap- 
sularis  anterior  spuria.  Exudates  due  to  iritis  may  almost  fill  the  anterior 
chamber  without  leaving  a  permanent  trace  on  the  anterior  capsule  of  tho 
lens.  More  frequently  an  organized  membrane  remains  partly  adherent 
to  the  iris  and  partly  to  the  capsule  of  the  lens.  These  adhesions  are  not 
to  be  classed  as  eataracta  spuria.  Still,  they  are  an  etiological  factor  in  the 
development  of  true  cataract. 

"THE  VARIOUS  FORMS  OF  TRUE  CATARACTS.  Anatomically 
considered,  true  cataracts  are  divided  into  capsular  and  lenticular,  eataracta 
capsularis  and  eataracta  Unticularis.  The  latter  is  again  divided  into 
cortical  and  nuclear,  eataracta  lenticuJaris  corticalis  and  eataracta  Untic- 
ularis nuclearis.  If  both  nucleus  and  cortex  are  cloudy,  one  speaks  of 
eataracta  Unticularis  totalis:  if  there  is  both  capsular  and  lenticular  cata- 


23  Walter  von   .Viiunoti.   .Touiiuil     fm-    ('hifurs.M»'    und   Aujit'iiluMlkuiulf   Neuo 
Folge.  Bd.  VI.  1S4T. 


"3 
ract,  this  is  desigTiatotl  as  cafarada  capsulo-hnticularis.  Where  tlie  chjudi- 
ness  is  in  the  axis  of  the  lens,  one  speaks  of  a  central  cataract,  or  catarada 
ceniralis:  a  better  name,  however,  is  axial  cataract,  catarada  axialis.  De- 
pending on  the  part  of  the  axis  in  which  the  cloudiness  is  located,  one  dif- 
ferentiates between  a  catarada  centralis  lenticular  is,  the  seat  of  the  cloudi- 
ness being  in  the  centre  of  the  lens,  from  a  catarada  centralis  anterior  or 
posterior.  Here  again  a  separation  ought  to  be  made  between  catarada 
centralis  capsularis  anterior  and  posterior  and  catarada  corticalis  anterior 
and  posterior.    Equatorial  and  meridional  cataracts  are  also  spoken  of." 

"At  times  we  meet  with  opacities  of  the  lens  which  are  partial;  then 
again,  others  which  are  complete.  But  since  every  complete  opacity  must 
at  the  time  of  its  development  have  been  partial,  the  name  partial  cataract 
has  been  applied  to  those  cases  which  clinical  experience  has  proven  to  re- 
main stationary  during  the  whole  of  life,  or  at  least  during  a  great  many 
years.  On  this  account,  the  following  expressions,  cataracta  partialis  and 
cataracta  stationare;  also,  catarada  totalis  and  cataracta  progressiva  have 
come  into  use." 

"The  former  are  often  the  result  of  errors  in  the  original  formation, 
hence  congenital.  There  are,  however,  congenital  cataracts  which  are  not 
partial,  cataracta  congenita  and  acquisita." 

"The  grey  cataract  may  develop  at  any  time  of  life.  It  is,  however, 
more  frequently  met  with  in  children  and  the  aged,  than  in  people  in  the 
middle  period  of  life — cataracta  jnvenum  and  cataracta  senilis.  Cataracts 
occurring  in  children  are  usually  classed  with  the  cataracta  congenita." 

This  separation  is  of  practical  value,  since  the  consistency  of  the  cata- 
ract to  a  large  degree  depends  on  the  age  of  the  individual.  Cataracts  of 
the  young  as  a  rule  are  soft;  in  the  aged  they  are  either  hard  or  of  a  mixed 
consistency;  in  the  latter,  where  the  nucleus  is  hard  and  the  cortex  soft — 
catarada  mollis,  dura  and  mixta.  The  extremes  of  these  varieties  are 
called  cataracta  fiuida,  cataracta  ladea,  cataracta  lapida,  calcarea,  ossea 
and  cataracta  Morgagni.  Some  of  these  expressions  will  be  met  with  again, 
when  we  come  to  consider  and  divide  forms  of  cataract  due  to  the  products 
of  chemical  disintegration,  or  new  formation — cataracta  gypsea.  calcarea, 
ossea,  putrida  idioreni  tenens." 

"Though  there  are  good  grounds  for  considering  eyes  in  which  cata- 
ract develops,  as  otherwise  diseased,  still  in  most  cases,  aside  from  the 
cataract  one  is  not  able  to  discover  any  special  disease.  In  these  cases  the 
cloudiness  develops  primarily.  There  are,  however,  certain  diseases  of  the 
eye  to  which  frequently  or  at  certain  stages  the  grey  cataract  is  secondarily 
added;  this  form,  together  with  all  cataracts  which  are  due  to  constitu- 
tional diseases  or  diatheses  are  today  designated  as  consecutive  cataracts. 


114 

(See  page  99).  This  avoids  the  confusion  which  formerly  existed,  since 
formerly  the  consecutive  cataracts  were  designated  as  secondar}' — together 
with  the  ''nachstaar/  the  cataract  which  develops  subsequent  to  a  cataract 
extraction,  and  which  today  are  considered  as  true  catarada  secundaria.'' 

"The  conception  of  the  complicated  cataracts  is  somewhat  more  gen- 
eral. Every  consecutive  cataract  is  also  a  complicated  one,  since  it  is  a 
complication  of  the  underlying  causes  which  have  led  to  the  formation  of 
a  cataract.  The  cataract  may,  however,  develop,  without  depending  on  any 
general  disease,  in  an  eye  which  is  diseased  and  in  such  a  manner  as  to  in- 
fluence the  result  of  an  operation  or  the  probability  of  a  cure.  In  such  d 
case  we  are  dealing  with  a  complicated  cataract,  which,  however,  is  truly 
a  primary  formation,  cataracta  complicata.  Thus,  in  consequence  of  glau- 
coma, a  cataract  may  develop,  cataracta  glaucomatosa;  and  this,  though  a 
secondary  cataract,  would  also  be  a  complicated  one.  Where  glaucoma 
develops  in  an  eye  previously,  simultaneously,  or  after  the  grey  cataract 
has  developed,  independently  of  the  cataract.  This  should  be  designated 
as  cataracta  in  oculo  glaucomate  afferto,  and  ought  to  be  considered  as  :i 
primaiy  cataract,  but  complicated." 

'<The  stages  of  the  development  of  cataract  become  of  especial  im- 
portance, owing  to  the  choosing  of  the  proper  time  for  operation.  Hence 
we  are  compelled  to  designate  the  various  stages,  cataracta  incipiens, 
nondum  matura,  maturesence,  maiiira  and  hypermatura.  At  times  the 
volume  of  the  cataract  is  dependent  on  the  stage  of  its  development.  A 
very  rapidly  developing  cataract  has  a  larger  volume  than  the  normal 
cataracta  tumescens;  whereas,  an  over-ripe  cataract  frequently  has  a  miich 
smaller  volume.  This  shrinkage  often  reaches  a  high  degree  when  the 
cataract  is  a  congenital  one,  or  develops  during  the  first  years  of  life,  or 
after  an  injury,  especially  when  the  lens  becomes  loosened  from  its  zonular 
attachment.  In  cases  where  the  anterior  and  posterior  capsule  almost 
touch  each  other,  the  cataract  has  received  the  name,  cataracta  mem- 
branacea.  If  the  folded  capsule  covers  a  small,  hardened,  shrunken  remains 
of  a  lens,  simulating  in  its  appearance  a  pea  in  its  covering,  which  had  been 
picked  before  it  was  ripe  and  then  dried,  one  then  speaks  of  a  cataracta 
arido  siliqvata." 

"Depending  on  their  color,  some  special  varieties  have  been  called 
cataracta  laciea;  also,  black-grey  cataract,  known  as  cataracta  nigra.  In 
the  diagnosis  of  the  consistency  of  a  cataract,  the  color  plays  an  important 
role. 

"If  a  cataract,  no  matter  what  its  variety  may  be.  is  complicated  by 
posterior  synechia,  which  bind  it  to  the  iris,  il  is  known  as  cataracta 
accreta.     If,  however,  the  zonula  is  partially  or  completely  ruptured,  so 


that  the  cataract  is  movable,  we  speak  ol:  this  as  a  cataracla  inmuJa,  natalis, 
or  natans." 

"After  it  had  been  recognized  tluit  the  seat  of  cataract  is  in  the  lens,  it 
did  not  take  King  nntil  a  great  variety  of  forms  and  classifications  were 
made.  Laperoue  and  Morand  were  the  first  to  differentiate  between  lentic- 
vlar  and  capsular  cataracts,  and  ,drew  especial  attention  to  the  fact  that 
the  latter  was  not  a  deposit  in  the  pupil,  but  an  opacity  of  the  capsule. 
St.  Yves  was  the  first  to  point  out  the  fact  that  the  cataract  may  be  a 
congenital  anomaly.  He  likewise  was  the  first  to  classify  as  special  varie- 
ties Hhe  milk'  and  'the  pus'  cataracts.  On  'milk  cataract,'  which  he  looked 
upon  as  a  'tumor  cysticus/  we  received  a  special  dissertation  by  Roscius 
(1740).  The  following  year,  Morgagni  (1.  c,  VI.  90)  denied  that  the  lens 
possessed  any  blood-vessels,  and  asserted  that  cataract  was  due  to  a  lack 
and  an  improper  nutritive  supply.  This  nutritive  fluid  was  named,  after 
him,  liquor  Morgagni;  and  his  view  for  many  years  exerted  an  important 
influence  on  the  classifications  of  cataract.  He  considered  the  capsule  as 
a  second  seat  of  cataract.  According  to  his  view,  the  lens  was  always  sec- 
ondarily affected.  J.  G.  Gunz  (7-11)  says  the  cataract  may  have  a  three- 
fold seat." 

"He  speaks  of  spvriae,  when  the  cataract  is  seated  in  the  aqueous, 
verae  when  in  the  lens,  mixtae  when  it  has  its  seat  in  both.  The  verae  he 
divided  into  lens  and  capsular  cataracts.  The  latter  are  either  anterior 
adversae  or  posterior  aversae.  The  capsular  cataracts  he  called  cataracta 
compositae  crystalhnae.  Peter  Guerin  was  the  first  to  separate  the  primary 
from  the  secondary  cataract,  and  was  the  first  to  mention  the  cataracta 
traumatica.  Jean  Janin,  whose  anatomical  investigations  are  today  of 
value,  was  the  first  to  show  that  the  lens  is  neither  a  continuation  of  ths 
hyaloid  nor  of  the  retina.  He  drew  a  sharp  line  of  distinction  between 
the  capsular  and  lenticular  cataracts,  and  declared  that  ]\Iaitre  Jean's  pus 
cataract  is  a  cataracta  Morgagniana.  According  to  their  stage  of  develop- 
ment, he  separated  cataracts  into  cataracta  incipiens  and  cataracta  com- 
pleta.  He  designated  as  ripe,  the  cataract  which  had  become  loosened  from 
its  connection,  so  tliat  "a  sinking  down'  had  followed.  He  also  considered 
very  fully  the  subjects  of  the  operation  for,  and  the  development  of,  sec- 
ondary cataracts.  Finally,  he  was  the  first  to  give  an  accurate  description 
of  cataracta  nigra.  A.  G.  Richter  (1773)  separated  cataracts  into  gelatin- 
ous, milky,  {pnrulenta,  cataracta  cystica  autorum),  caseous,  horny,  and 
those  of  stony  consistency.  To  G.  A.  Schmidt  are  we  indebted  for  formu- 
lating our  first  conception  of  cataracta  natalis.  (the  cataracta  tremula — 
Richter),  cataracta  pyramidata,  cataracta  capsularis  arida  siliqvata,  the 
cataracta  capsularis  cum  Inrsa  ichoremcontineiite, cataracta  Irabecularis  and 


arboresences.  Beer  (1817)  again  took  up  the  old  classification  of  Gunz,  of 
the  true  and  false  cataracts,  and  the  latter  he  divided  into  a  number  ot 
special  varieties.  This  brought  discredit  to  his  work  in  later  years.  Still, 
one  should  not  forget,  that  the  clinical  pictures  which  he  portrayed  are  a 
positive  masterpiece,  so  that  even  at  the  present  day  his  first  chapter  is 
worthy  of  careful  study.  With  but  few  exceptions,  his  clinical  pictures  are 
as  true  today  as  when  they  were  written." 

"The  important  differences  between  lenticular  and  capsular  cataracts 
was  vigorously  opposed  by  Malgaigne,  and  he  had  many  adherents  to  his 
belief.  He  denied  the  existence  of  capsular  cataract,  and  based  his  opinion 
on  twenty-five  dissections  of  cataractous  lenses.  The  outcome  of  this  long 
discussion  finally  led  to  a  different  anatomical  definition  of  capsular  cat- 
aract, so  that  one  might  more  readily  recognize  it  during  life.  Malgaigne 
was  correct  when  he  asserted  that  that,  which  up  to  that  time  had  been 
called  a  capsular  cataract,  was  in  fact  a  cortical  cataract.  This  is  further 
evidenced  by  the  clinical  records  of  that  time,  for  the  capsular  cataract  of 
that  time  was  often  said  to  have  been  completely  absorbed  after  the  opera- 
tion. We,  however,  know  today  that  the  capsular  cataract  remains  entirely 
unchanged  by  the  action  of  the  aqueous  humor." 

"The  expression  'liquor  Morgagni'  is  an  obsolete  expression  for  the 
tissue  fluids  found  between  the  individual  lens  fibres.  If  this  expression  is 
retained,  one  more  form  of  cataract  must  be  enumerated,  catarada  stellata. 
The  form  catarada  Morgagni  is  due  to  an  entirely  different  cause." 

THE  DIAGNOSTIC  FEATUREiS  OF  CATARACT.  "Xearly  all 
those  characteristics  which  aid  us  in  making  the  finer  distinctions  between 
the  various  forms  of  cataract  can  be  observed  by  the  eye,  or  be  determined 
by  visible  peculiarities,  such  as  their  consistence.  Therefore,  the  diag- 
nosis of  grey  cataract  is  pre-eminently  an  objective  one.  However,  the 
vastly  improved  methods  of  examination  which  have  come  into  vogue  have 
greatly  facilitated  this  work.  By  this,  I  mean  the  oblique  or  focal  illumina- 
tion, the  easy  and  convenient  use  of  the  alkaloid  of  belladonna,  sulphate  of 
atropine;  also,  homatropine,  and  at  a  still  later  day,  of  cocaine,  and  the 
refracting  opthalmoscope."  The  opthalmoscope  dates  back  to  the  year 
1851,  whereas  atropine  is  older,  Himly  having  spoken  of  it  in  1806.  (289, 
p.  3.5).  Cocaine  was  introduced  into  opthalmology  by  Koller  in  1882. 
The  present  state  of  the  completeness  of  diagnosis,  has  been  attained  as 
the  result  of  the  impetus  given  by  Helmholz  to  Yon  Graefe  and  Liebreich,^' 
and  at  a  still  later  day  to  Hirschberg,  Magnus,  Schoen  and  others.     The 


24  Arch.  f.  Opth.,  I,  2,  p.  3."j1. 


117 
combined  use  of  a  mydriatic  and  the  refracting  optliahnoscope  have  raised 
the  diagnosis  of  cataract,  to  a  positive  position,  as  a  result  of  the  objective 
examination  of  tlie  eye. 

"If,  by  means  of  a  lens  of  short  focal  length,  one  concentrates  the 
light  from  a  lamp,  on  the  pupil  of  an  eye  dilated  by  a  mydriatic,  one  sees 
nothing  of  the  parenchyma  of  the  lens,  if  the  individual  is  young.  Under 
certain  conditions,  one  does  see  the  reflected  images  of  the  light  on  both 
surfaces  of  the  lens— but  nothing  more.  However,  even  in  children,  if 
one  accurately  concentrates  the  point  of  a  bundle  of  rays  exactly  in  the 
centre  of  the  puj)!!.  one  may  get  a  very  faint  greyish  reflex,  which  moves 
simultaneously  with  tlie  movement  of  the  lens.  This  grey  reflex,  however, 
never  becomes  so  ])ronounced,  as  its  analogous  phenomenon  when  practiced 
on  the  transparent  cornea. 

In  older  individuals,  as  early  as  the  twentieth  year,  the  anterior  surface 
of  the  lens  discloses  a  faint  silky  gloss.  That  this  does  not  originate  in  the 
capsule,  but  in  the  most  superficial  layers  of  the  lens,  is  evident,  notwith- 
standing the  fact  that  it  seems  to  be  in  the  same  plane  with  the  edge  of  the 
pupil,  because  one  simultaneously  sees  the  radiating  striae,  also  the  anterior 
lens  star  and  its  wedge-shaped  spaces.  About  the  thirtieth  year,  often  not 
until  near  the  fortieth  year,  one  observes  in  the  depth  of  the  lens  a  faint, 
and  increasing  with  years,  a  gradually  increasing  yellowish  reflex,  the  sure 
sign  of  the  formation  of  the  senile  nucleus.  As  age  advances,  the  silken 
gloss  increases  and  the  anatomical  arrangement  of  the  lens  fibres  becomes 
more  distinctly  perceptible,  and  the  yellowish  reflex  becomes  a  more  dis- 
tinct red.  In  exceptional  cases,  perhaps  where  the  equatorial  diameter  of 
the  lens  is  abnormally  small  or  where  the  base  of  the  cornea  is  very  large, 
one  will  observe,  when  the  pupil  has  been  dilated  ad  maximum,  that  the 
edge  of  the  lens  is  reflected  as  a  yellow  ring.  In  very  exceptional  cases, 
one  can  perceive  at  the  equator  of  the  lens  fine  radiating  lines,  which  ex- 
tend beyond  the  edge  of  the  lens,  and  these  must  be  looked  upon  as  the 
insertion  of  the  zonula  fibres.  In  cases  of  congenital  and  acquired  coloboma 
of  the  iris  one  can  often  see  the  edge  of  the  lens,  but  even  then  the  zonula 
fibres  are  but  rarely  seen.  In  advanced  age  there  appears,  however,  beside 
the  equatorial  marked  contour,  somewhat  inward  from  this,  a  second  con- 
centric grey  cloudiness  (gerontoxon  lentis),  without,  however,  on  this 
account  an  actual  cloudiness  being  present. 

In  the  aged,  as  is  well  known,  the  pupil  no  longer  has  the  pure  black 
color,  as  it  exists  in  children.  The  more  dilated  the  pupil,  the  more 
noticeable  this  becomes.  As  a  result,  in  an  eye  under  the  influence  of  a 
mydriatic,  one  observes,  even  with  the  naked  eye,  (more  distinctly,  how- 
ever, by  focal  illumination  and  especially  frequent  in  myopic  eyes),  the 


JiS 

nucleus  of  the  lens  encased  in  a  globular,  cloudy  opacity,  with  a  gradually 
fading,  washed-out  periphery,  whereas  the  zone  more  toward  the  equator 
appears  darker;  that  is,  is  more  transparent. 

The  warning  can  not  be  too  emphatically  stated,  to  beware  of  making 
a  diagnosis  of  cloudiness  of  the  lens,  and  of  cataract,  when  such  reflexes 
are  present.  The  diagnosis  is  onh/  then  permissahle  when  examination  with 
the  opthahnoscope  discloses  non-transparent  spots  or  opacities,  in  the  same 
places  where  these  reflexes  tvere  observed  on  focal  illuminatio7i. 

In  making  the  examination  by  means  of  the  opthalmoscope,  the  rays 
reflected  from  the  fundus  are  the  important  ones,  not  the  incident  rays. 
By  means  of  the  mirror,  an  illuminated  field  is  created  behind  the  lens,  in 
front  of  which  field,  the  entirely  transparent  medium,  the  lens,  seems  to 
float.  If  the  lens  system  is  likewise  clear,  aside  from  the  possible  reflexes 
on  the  surface  of  the  lens,  one  does  not  become  aware  of  its  presence.  If, 
however,  there  are  portions  which  are  not  fully  permeable  to  light,  these 
portions  will  appear  in  front  of  the  illuminated  background,  as  non- 
illuminated,  hence  dark  or  black  spots,  since  they  obstruct  the  returning 
light.  Therefore,  only  then,  after  those  centrally  located  grey,  cloudy 
masses  which  appear  on  focal  illumination,  likewise  appear  as  dark  spots 
on  opthalmoscopic  examination,  is  one  justified  in  making  a  diagnosis  of 
cataract.  Frequently  this  is  not  the  case.  However,  such  a  nuclear  cloudi- 
ness often  differentiates  itself  in  such  a  manner,  that  one  can  see,  in  the 
middle  of  the  dilated  pupil,  at  a  perceptible  distance  from  the  pupillary 
plane,  a  dark-red  globular  body.  But  one  can  easily  observe,  on  moving  the 
mirror,  that  the  contours  change  their  position,  so  that  this  phenomenon 
c^n  also  be  accepted  as  a  sign  of  total  reflection,  by  means  of  which  the 
non-homogenous,  strongly  light-reflecting  nucleus  has  separated  itself 
from  the  cortical  substance. 

According  to  Schweigger,  (1309,  a.  p.,  26),  by  means  of  focal  illumina- 
tion and  the  opthalmoscope,  one  can  determine  (in  myopes)  if  there  is  an 
abnormal  increase  in  the  index  of  refraction  of  the  nucleus  of  the  lens. 
Conducting  such  an  examination  with  the  naked  eye,  using  the  ordinary 
daylight,  (more  so,  however,  by  focal  illumination),  the  nucleus  of  such 
an  eye  reflects  more  light  than  does  a  normal  eye.  On  making  an  opthal- 
moscopic examination  with  a  plane  mirror,  tlie  nucleus  is  easily  differenti- 
ated from  the  cortex.  Tliis  is  most  easily  observed,  if  by  making  slight 
movements  with  the  mirror  one  tries  to  get  around  the  nucleus.  This 
change  is  frequently  one  of  the  partial  [)lienoiiienoii  of  myopia;  it  does, 
however,  also  occur  during  the  initial  stage  of  sn-called  mulear  cataract. 

Whereas,  on  focal  illumination,  the  edge  of  the  lens  appears  as  a  fatty 
or  glistening,  golden  ring,  on  use  of  reflected  light,  it  appears  as  an  equally 


119 

broad,  dark,  band-like  ring.  Tlie  incident  rays  of  light  are  met  near  the 
equator  by  the  rays  of  light  reflected  from  the  fundus  as  they  pass  from 
the  lens  into  the  aqueous  humor,  and  ai-e  totally  reflected  in  a  narrow  zone. 
This,  at  times  glistening,  at  times  black  ring,  grows  broader  during  the 
act  of  accommodation;  also,  in  cases  in  which  the  zonula  is  torn.  In  this 
way,  a  partial  tearing  of  the  zonula  can  be  diagnosticated.^^  Only  twice 
was  Becker  able  to  see  these  folds  and  the  insertion  of  the  zonula  fibres 
with  the  opthalmoscope. 

F.  Dimmer,26  states  that  "the  light  from  the  fundus  is  reflected  in 
such  a  manner  by  the  edge  of  the  lens  that  it  can  not  be  observed  by  the 
investigator  as  he  looks  through  the  little  hole  in  his  opthalmoscopic 
mirror.  This  edge,  however,  beconies  light  red  as  soon  as  the  observer's 
eye  is  brought  in  such  a  position  as  to  permit  the  reflected  light  to  enter 
the  pupil  of  the  observer.  Then,  however,  only  the  edge  appears  red.  In 
the  normal  lens  the  same  conditions  may  be  observed,  only  that  the  dark 
edge  is  narrower.  In  luxated  lenses,  which  assume  a  more  globular  form, 
the  reflection  of  light  along  the  edge  must  be  greater.  He  also  considers 
the  phenomenon  of  reflection  of  light  along  the  edge  of  the  lens,  by  focal 
illumination.  He  differs  from  all  authorities,  and  states  that  this  reflex  is 
only  visible  when  the  lens  is  in  its  normal  position,  (not  even  when  there 
U  a  large  defect  in  the  iris).  This  he  concludes  is  due  to  total  reflection  of 
light  on  the  posterior  surface  of  the  lens. 

In  the  alternating  use  of  focal  and  direct  illumination  with  a  dilated 
pupil,  we  have  at  our  command  the  absolute  means  of  finding  every;  in  fact,, 
the  minutest  opacities  of  the  lens;  of  recognizing  and  demonstrating  them. 
Only  then  does  the  opthalmoscope  lose  its  value  to  diagnosticate  cataract 
when  the  cloudiness  has  become  so  dense  and  advanced  to  such  a  degree  as 
to  pre\'^nt  the  light  being  reflected  from  the  deptlis  o^  the  fundus,  hence 
no  longer  giving  a  red  reflex.  On  illuminating  the  pupil  with  the  opthal- 
moscope, the  mirror  now  acts  just  as  it  does  on  focal  illumination.  In  such 
cases,  however,  the  presence  of  cataract  is  no  longer  a  mooted  question. 
The  more  accurate  diagnosis  as  to  the  quality  of  the  cataract  depends  on 
the  focal  illumination. 

The  following  statements  of  licckcr  are  especially  interesting  and  of 
historical  value,  since  tliey  Avere  made  l)efore  the  refracting  opthalmoscope 
had  come  into  use,  by  means  of  which  instrument,  as  has  been  pointed  out 
on  page  77,  it  has  become  possible  to  detect,  one  might  almost  say,  micro- 


25  A  study  for  making  the  edge  of  the  lens  visible,  see  "Function  der  Ciliar- 
fortsatze,"  AVien.  Med.  Yahr.  b.  1863,  S.  1G5. 

26Graefe  Arch.,  Vol.  XXXVIII.  B.  4,  18!l2.    "Beitrag  zur  OpthMlinoscope." 


scopical  changes  in  tlic  lens,  long  before  the.y  begin  to  make  themselves  a 
source  of  discomfort  and  annoyance  to  those  so  affected.  With  this  instru- 
ment, it  is  possible  to  study  the  development  of  cataract  from  its  very  in- 
cipiency  and,  one  might  say,  to  focus  every  lamella  of  the  lens.  Becker 
says,  "In  the  examination  of  partial  and  incomplete  cataract  formations, 
the  opthalmoscope  is  especially  valuable.  Here  it  serves,  not  only  to  give 
a  more  intense  illumination,  but  acts  as  a  magnifying  glass.  To  accomplish 
this,  a  myope  must  approach  the  eye  to  the  distance  of  his  near  point,  the 
emmetrope  and  hyperope  must  make  himself  a  myope  by  adding  a  convex 
glass  to  his  opthalmoscope.  A'ery  advantageous  in  such  cases  is  the 
method  suggested  by  Mauthner,  Liebreich  and  Becker,  by  the  direct  method, 
placing  a  strong  convex  glass  between  the  mirror  and  the  eye,  as  near  as 
possible  to  the  latter.  Himly  ^^  attempted  to  accompHsh  the  same  end  and 
proposed  putting  a  pair  of  "cataract  glasses"  on  the  cataract  patient  and 
then  making  the  examination  by  a  bright  illumination.  Such  an  examina- 
tion can  almost  be  considered  a  microscopical  one.  True,  by  this  method, 
one  has  not  been  able  to  discover  any  new  facts,  but  the  ability  to  decide 
the  relative  position  of  the  cloudy  portions  to  each  other  has  been  made 
very  much  easier.  By  bringing  a  two-inch  (20  D.)  lens  as  close  as  possible 
to  the  cornea,  one  can  easily  approach  the  posterior  pole  of  the  lens.  This 
method  will  become  still  more  prevalent  in  examinations  of  secondary  cata- 
racts, cataraeta  accreta,  capsular  cataracts,  and  posterior  polar  cataracts. 
Thus  we  see  that  though  they  did  not  possess  the  valuable  instrument 
(refracting  opthalmoscope),  they  were  already  on  the  right  road  to  its  de- 
velopment. 

The  opthalmoscope  also  aids  us  in  differentiating  between  cloudiness 
in  the  lens  and  other  media. of  the  eye.  Macula  corneae  can  be  recognized 
by  focal  illumination,  but  when  vitreous  opacities  are  present,  the  opthal- 
moscope at  once  demonstrates  its  great  value. 

.  If  the  eye  is  held  perfectly  still  and  the  fundus  illuminated  by  the 
mirror^  all  those  opacities  which  lie  in  the  line  of  the  returning  rays  of 
light  will  appear  as  shadows  on  an  illuminated  background,  and  at  the 
same  time  will  appear  to  be  removed  a  certain  distance  from  the  edge  of 
the  pupil.  Thus  all  opacities  on  the  cornea,  in  the  lens  or  vitreous,  which 
lie  in  the  line  of  the  axis  of  vision  will  cover  each  other.  If,  however,  the 
observer  moves  his  head  and  the  mirror  slowly  to  one  side,  the  various 
opacities  lying  at  different  depths  will  not  only  shift  their  relative  positions 
and  distance  to  each  other,  but  they  will  also  do  this  in  their  relation  to 
the  edge  of  the  pupil.    Only  those  opacities  which  lie  exactly  in  the  plan.3 

27  J.  B.  Fleury,  Di.ss.   Sur  la  Cataracte.    Paris. 


of  the  pupil  do  not  change  their  distance  from  the  edge  of  the  pupil. 
Since,  where  the  topographical  relations  are  normal,  the  anterior  capsule  of 
the  lens  occupies  this  position,  this  relation  gives  us  a  positive  means  of 
recognizing  anterior  central  capsular  cataract;  also,  deposits  on  the  anterior 
capsule.  On  rotating  the  mirror,  those  opacities  most  anteriorly  situated 
seem  to  move  in  an  opposite  direction,  whereas  those  farthest  back  seem 
to  go  in  the  same  direction  as  the  edge  or  rim  of  the  mirror.  The  further 
they  are  removed  from  thejris,  the  more  rapid  appear  to  be  the  changes 
in  position.  Opacities  in  the  vitreous  seem  to  reach  the  edge  of  the 
illuminated  area  much  more  rapidly  than  do  opacities  in  the  lens,  and  like- 
wise disappear  more  rapidly  behind  the  iris.  If  the  observer  remains  quiet, 
and  the  examined  eye  is  moved,  all  the  phenomenon  take  place  in  an  exactly 
opposite  direction.  The  diagnosis  gains  in  certainty  because  vitreous  opaci- 
ties are  but  seldom  fixed,  and  as  a  rule  they  move  about,  even  after  the 
eye  has  been  brought  to  rest.  Hence  it  is  always  necessary  to  examine  by 
both  methods.28  In  exceptional  cases,  it  may  become  necessary  to  prove 
that  the  lens  is  present  in  the  pupillary  area.  For  this  purpose,  we  avail 
ourselves  of  the  images  reflected  on  the  surface  of  the  lens.  The  appear- 
ance of  but  one  of  the  images  is  sufficient  to  demonstrate  positively  the 
presence  of  the  lens.  Before  the  invention  of  the  opthalmoscope,  and  be- 
fore its  methods  of  use  had  been  perfected,  the  examination  by  focal 
illumination  and  the  study  of  the  images  reflected  on  the  lens  were  of  the 
very  greatest  value.  This  method  was  introduced  into  opthalmology  by 
the  Parisian  oculist,  Sanson,  and  the  small  reflected  images  were  named 
after  him  and  their  discoverer,  Purkinje,  the  Purkinje-Sanson  pictures. 
Even  today,  this  method  will  conclusively  decide  whether  a  cloudiness 
near  the  posterior  capsule  is  in  front  of  or  behind  it.  if  there  be  an  opac- 
ity of  the  lens,  the  light  being  placed  in  a  certain  position,  the  reflected 
image  will  either  disappear  entirely  or  become  more  or  less  indistinct  at  the 
point  corresponding  to  this  opacity.  If,  however,  this  opacity  is  in  the 
vitreous  instead  of  in  the  lens,  the  reflected  image  will  not  only  be  present 
in  the  posterior  capsule,  but  in  some  instances  it  will  become  even  more 
distinct  and  stand  out  more  clearly. 

In  diagnosing  diffuse  opacities  of  the  lens,  these  reflected  images 
become  valuable.  Whereas  the  picture  on  the  anterior  capsule  can  be  made 
visible  everywhere,  that  on  the  posterior  capsule  will  appear  blurred, 
(''washed  out"),  or  entirely  hidden.  Mauthner  (1.  c,  p.  148)  observed  a 
most  peculiar  condition  of  this  picture,  it  appearing  to  him  blood-red.  This 
peculiar  color  determines  the  presence  of  a  diffuse  cloudiness  of  the  lens. 

28  Liebrich,  1.  c,  4S<;.     Mauthner,  c.  p.,  ].'53. 


A  fiiint  rcddisli  line  is  almost  always  present,  even  when  the  picture  is  but 
slightly  blurred.  This  is  due,  as  is  well  known,  to  the  influence  which 
cloudy  media  exert  on  mixed  rays  of  light;  the  same  reason  causes  the 
settling  sun  to  appear  red.  Ignorance  of  this  fact  has  more  than  once  led 
to  the  diagnosis  of  the  presence  of  blood  or  blood  coloring  matter  in  the 
lens.  Eeuti  ^9  passingly  makes  this  remark,  to  which  I  desire  to  call  at- 
tention. He  says,  (speaking  of  the  lens  capsule  as  a  permeable  membrane 
which  permits  endosmosis),  "This  explains  the  reason,  why  at  times  the 
lens  takes  on  a  red  color  when  the  coloring  matter  is  present  in  the  vitreous 
and  aqueous. 

Case.  "  An  aged  nurse  wa.s  struck  with  a  whip  in  the  right  eye  by  her  mis- 
tress. The  slight  injury  to  the  lid  healed  readily.  Though  externally  the  eye 
appeared  normal,  the  woman  declared  that  she  could  see  nothing  with  that  eye, 
and  the  family  not  believing  her,  she  brought  suit  for  damages.  The  pupil  was 
round,  black  and  reacted  to  light.  As  a  result,  the  doctors  who  examined  her  at 
the  trial,  stated  that  the  woman's  declaration  was  untrue.  She  then  applied 
at  the  clinic  of  Prof.  Yaeger,  and  the  examination  revealed  the  fact  that  no 
light  was  reflected  from  the  fundus.  The  Purkinje-Sanson  pictures,  however, 
proved  that  the  lens  w^as  present  in  its  proper  place.  Projection  of  light  was 
retained  in  all  directions,  fingers,  however,  could  not  be  counted.  The  retina 
must,  therefore,  have  been  everywhere  adherent  to  the  choroid,  and  the  disturb- 
ance of  vision  must  necessarily  have  been  due  to  a  large  amount  of  blood  in  the 
vitreous." 

Liebreich's  corneal  microscope  is  also  useful,  especially  in  examining 
the  anterior  portion  of  the  lens.  By  this  method  one  is  able  to  differentiate 
much  more  easily  than  by  focal  illumination,  anterior  cortical  cataract, 
capsular  cataracts  and  deposits  on  the  anterior  layer  of  the  capsule.  In 
examinations  of  secondary  cataracts  and  cases  of  occlusion  of  the  pupil  after 
cataract  operations,  this  instrument  is  of  service  and  may  be  of  great  value 
more  especially  in  determining  with  certainty,  whether  or  not  new-formed 
vessels  are  present  in  this  secondar}-  cataract.  If  a  binocular  microscope  is 
used,  the  very  important  point,  (namely,  the  decision  as  to  the  seat  and 
position  of  the  opacity)  is  made  much  easier. 

The  application  of  the  same  principle  in  a  simple  manner,  consists 
in  the  use  of  a  lens,  whik'  practicing  focal  illumination.  This  method  was 
also  recommended  by  Mauthner  (1.  c,  p.  136).  One  can  use  as  a  corneal 
loup,  a  simple  convex  lens,  such  as  every  doctor  carries  in  his  vest  pocket. 
For  clinical  demonstration,  the  binocular  lens  should  certainly  be  preferred 
to  an  ordinary  reading  glass.  Owing  to  the  stereoscopic  distortion,  the  dif- 
ferences in  depth  stand  out  very  distinctly. 


29  Handworterbuch  der  Physiologle,  III.  2,  S.,  235. 


123 

The  examination  by  the  above-mentioned  methods  gives  such  great 
and  positive  assistance  in  determining  with  certainty  the  presence  of  opaci- 
tes  in  the  crystalline  lens,  that  the  examination  by  ordinary  daylight  with- 
out the  aid  of  optical  appliances  has,  with  right,  been  relegated  to  the  past. 
It  is  true  that  one  may  recognize  not  only  the  mature  or  nearly  total  cata- 
ract, with  the  naked  eye,  but  even  at  times  the  partial  cataract.  It  is  also 
true  that  a  trained  eye  can  not  overlook  the  central  capsular  cataract,  a 
central  lens  cataract  or  other  forms  which  are  apparent.  But  one  can  not 
warn  too  often  against  making  a  diagnosis  with  the  naked  eye,  of  cataract 
in  every  case  of  discernible  opacity  back  of  the  pupil  in  old  people.  A  very 
apparent  and  perceptible  grey  color  of  the  lens  may  be  due  to  senile  scler- 
osis of  the  lens. 

The  presence  of  cholesterine  in  the  lens  gives  it  a  most  peculiar  ap- 
pearance. Even  with  the  naked  eye,  one  at  once  recognizes  the  fine  glisten- 
ing points.  Where  a  large  number  of  these  crystals  are  present,  on  focal 
illumination  they  may  take  on  a  stary  appearance.  As  a  rule,  they  give  no 
evidence  of  movements.  However,  if  the  cortex  has  become  fluid,  they  can 
be  seen  to  move  about.  The  presence  of  these  crystals  always  signifies  that 
not  only  a  retrogressive  metamorphosis  has  set  in,  but  that  it  is  already 
somewhat  advanced.  Consequently,  they  are  only  found  in  over-ripe  cata- 
racts. They  develop  more  frequently,  however,  in  the  soft  cataracts  of 
youth. 

A  most  interesting  case  is  described  by  Van  Graefe,30  in  which  the  nucleus 
•was  totally  transparent,  and  the  cortical  substance  between  the  individual  con- 
glomerations of  crystals  seemed  to  be  but  slightly  affected,  as  though  they  had 
been  breathed  on.  Though  light  was  reflected  from  the  fundus,  it  was  very 
difficult  to  gain  a  distinct  view  of  the  fundus.  In  the  other  eye  this  woman,  who 
was  73  years  of  age.  had  a  Cataracta  Morgagni. 

"THE  SUBJECTIVE  SYMPTOMS  which  axe  caused  by  grey  cata- 
racts are,  generally  speaking,  those  due  to  disturbance  of  vision.  Before 
the  invention  of  the  opthalmoscope,  by  subjective  symptoms  alone,  cata- 
racta incipiens  was  recognized,  or  rather  concluded  to  be  present.  Among 
the  older  works  on  the  eye — and  I  will  mention  one,  which  is  just  on  the 
border-line  of  the  new  era  of  opthalmology,  'The  Pathology  of  the  Human 
Eye,'  by  Dalrymple,  1852 — the  consideration  of  the  subjective  symptoms 
is  given  a  strikingly  large  amount  of  space.  The  differential  diagnosis  be- 
tween beginning  optic  atrophy,  glaucoma  and  cataract  up  to  1852  knew  no 
aids  other  than  the  most  ingenious  use  of  the  subjective  symptoms."  To- 
day the  inability  to  recognize  a  beginning  cataract  is  confined  only  to  those 

30  Arch.  f.  Opth.,  17,  p.  323. 


124 

who  do  not  knou-  liow  to  use  the  opthalinoscope  in  a  methodical  manner. 
However,  even  today  a  knowledge  of  the  objective  symptoms  is  a  valuable 
adjunct.  Thev  teach  us  how  to  recognize  with  a  great  degree  of  certainty, 
even  without  an  examination,  the  cause  of  the  complaint  with  which  the 
patient  comes.  By  these  alone  it  is  possible,  when  a  mature  total  cataract 
is  present,  to  decide  if  a  complication  is  present  or  not." 

"According  to  Arlt.  (1.  c,  p.  277),  a  portion  of  the  disturbances  of 
vision  which  must  follow  where  a  lens  is  affected  with  a  partial  cataract 
can  be  studied  by  the  following  experiments.  He  uses  a  lens  having  a  focal 
length  of  two  inches  and  fastens  on  this,  globules  and  striae  of  w^ax,  of 
different  sizes  and  form,  some  on  the  anterior,  some  on  the  posterior  sur- 
face, some  in  the  region  of  the  pole,  some  on  the  edges.  By  cementing  to- 
gether two  plano-convex  lenses  between  which  has  been  placed  a  circular 
piece  of  paper,  either  partially  transparent  or  totally  dense,  leaving  a 
greater  or  less  wide  transparent  margin  around  the  periphery,  the  nuclear 
cataract  can  be  imitated.  At  the  same  time,  by  holding  in  front  of  this 
diaphragms  of  various  sizes,  one  can  demonstrate  the  influence  of  a  wide 
or  a  narrow  pupil.  The  image  of  a  window  or  a  lamp,  thrown  up  by  a  lens 
treated  in  this  manner,  can  be  caught  in  the  room  on  a  white  paper  screen. 
Such  experiments  become  very  elegant,  when  a  camera  obscura  is  used,  or 
an  apparatus  such  as  is  used  by  me  (Becker)  in  demonstrating,  the  anoma- 
lies of  refraction."  By  means  of  a  water  trough  placed  between  the  lens 
and  a  ground-glass  plate,  the  influence  of  such  opacities  on  the  form  and 
direction  of  these  deflected  bundles  of  rays  can  be  very  prettily  shown.  By 
the  combination  of  two  plano-convex  glasses,  between  which  various  thick- 
nesses of  paper  have  been  fastened  and  then  cemented  together  with  Can- 
ada balsam,  one  possesses  a  splendid  means  of  demonstrating  the  influence 
of  total  cataract  on  vision.  More  especially  the  fact,  that  in  cases  of  total 
cataract  the  power  of  projection  of  light  is  retained  by  the  retina,  is  worthy 
of  experimental  demonstration  in  the  clinic  before  the  students.  Generally 
speaking,  the  disturbance  of  vision  dependent  on  grey  cataract,  at  first  in- 
terfere with  the  accuracy  of  distinguishing  objects  at  a  distance;  gradually 
this  is  also  lost  for  near,  until  finally  objects  can  no  longer  be  recog- 
nized by  their  contours,  without  ever  at  any  time  sensation  to  light  or  the 
appreciation  of  color  being  lost.  This  is  true  of  partial  as  well  as  of  total 
cataracts.  Nevertheless,  disturbances  of  vision  in  both  forms  deserve  a 
separate  consideration."" 

"PAirriAT.  CATAKACTS,  when  small  or  located  in  the  periphery, 
have  such  unimportant  influence  on  the  eye,  that  the  individual  does  not 
feel  necessitated  to  have  the  eye  examined.  Such  stationary  opacities  at 
times  are  accidentally  met  witb.     If  such  stationary  opacities  are  larger, 


125 

they  cause  an  unsymmetrical  refraction  of  the  rays  of  light  in  the  trans- 
parent portions  of  the  lens  and  can  give  rise  to  lenticular  astygmatism. 
Opacities  situated  directly  in  the  axis  of  the  lens,  often  congenital,  need 
not  necessarily  give  rise  to  disturbances  of  vision.  In  and  of  themselves, 
they  only  cause  a  less  amount  of  light  to  take  part  in  the  formation  of  the 
retinal  images;  consequently,  they  only  influence  the  brightness  of  the 
image.  The  sharp  outline  of  the  retinal  image  is  influenced,  when  the 
opacity  in  the  lens  is  not  sharply  defined  or  is  not  perfectly  opaque,  so  that 
the  diffuse  light  shed  on  the  retina  makes  the  image  appear  as  though  cov- 
ered by  a  veil.  This  also  occurs  frequently  where  there  is  an  anterior  cen- 
tral capsular  cataract,  and  this  always  occurs  where  there  is  a  posterior 
polar  cataract,  and  the  capsule  has  lost  its  convexity  and  become  wrinkled. 
Very  large  axial  cataracts  can  greatly  disturb  vision,  because  they  may 
totally  block  the  pupillary  area.  If  experience  teaches  us  that  the  axial 
cataract  is  frequently  associated  with  nystagmus  and  very  reduced  vision, 
it  is  not  to  be  assumed,  as  is  shown  by  Rente,  that  this  condition  of  nystag- 
mus is  the  result  of  the  axial  cataract,  but  the  cause  of  both  the  cataract 
and  the  nystagmus  is  to  be  sought  in  the  lack  of  development  in  size." 

"Zonular  cataract  is  deserving  of  especial  mention.  Such  eyes  are 
myopic,  and  have  reduced  vision.  The  myopia  is  due  in  part  to  the  fact, 
that  only  those  rays  of  light  come  together  to  form  the  retinal  image  which 
pass  through  the  edge  of  the  lens;  partially  due  to  the  eye  strain  developed 
while  looking  at  near  objects." 

"During  the  earliest  years  of  life,  such  patients  see  best,  for  though 
the  zonular  cataract  remains  stationary,  it  will  become  more  compact  as 
long  as  the  individual  continues  to  grow.  If  the  lamella  in  which  the 
opacity  is  located  is  very  thin,  even  if  thi-s  be  not  continuous,  the  patient 
will  see  by  means  of  the  rays  of  light  which  pass  through  the  cataract.  The 
more  the  light  is  cut  off  by  the  zonular  cataract,  the  more  the  patient  will 
be  dependent  on  the  light  which  passes  through  the  periphery  of  the  lens. 
He  will  therefore  see  better  when  the  pupil  is  dilated.  If  the  zonular  cata- 
ract progresses,  the  effect  will  be  exactly  the  same  as  though  there  were  a 
total  cataract." 

TOTAL  CATARACT.  Philip  von  Walter  (1.  c,  p.  48)  claims  to  have 
observed  that  just  previous  to  the  development  of  the  cloudiness  in  the 
lens,  the  features  of  the  patient  are  especially  clear  and  sharply  defined. 
Later  authorities  have  not  been  able  to  verify  this  observation;  however, 
all  agree  with  him  in  another  observation,  namely,  that  during  the  forma- 
tion of  a  cataract  many  eyes  which  formerly  were  not,  become  myopic. 
Scarpa  ^^  supposed  that  this  was  due  to  the  fact,  that  in  cataracta  incipiens 

SiTraite  Practitiuqe  des  Maladies  des  Yeux.     Paris,  1802,  II. 


126 

the  lens  becomes  more  convex.  'Where  the  development  is  a  rapid  one, 
(therefore,  generally  speaking,  in  cases  of  soft  cataract),  there  is  a  marked 
convexity  of  the  anterior  surface  of  the  lens;  this,  however,  occurs  at  a 
time  when  vision  has  become  greatly  reduced,  so  that  the  question  of  myopia 
is  no  longer  to  be  considered.  Arlt  has  as«gned  a  better  reason  (1.  c,  p.  II., 
278).  According  to  him,  myopia  only  occurs  then,  when  the  opacities  are 
of  such  a  size,  and  in  such  a  position,  as  to  prevent  the  passage  of  rays  of 
light  through  the  axis  and  adjacent  parts  of  the  lens,  so  that  only  those 
rays  which  pass  tlirongh  the  periphery  of  the  lens  are  brought  to  a  focus. 
The  condition  of  the  lens  influences  the  character  of  the  image  produced 
on  the  retina,  in  that  it  is  poorly  illuminated,  is  faint  and  indistinct,  and, 
all  things  being  equal,  not  so  far  away  from  the  lens.  This  also  explains 
why  it  is,  that  every  cataract  which  originates  in  the  centre  of  the  lens  in- 
terferes with  the  proper  perception  and  differentiation  of  distant  objects. 

However,  one  should  not  overlook  the  fact,  that  a  portion  of  this 
myopia  is  only  apparent.  The  fact  is  undoubtedly  true,  that  in  incipient 
cataract  objects  of  a  certain  size  must  be  brought  closer,  in  order  to  be  rec- 
ognized. Here  we  are  dealing  with  a  condition  similar  to  that  observed  in 
amblyopia,  and  as  is  especially  noted  in  high  degrees  of  hyperopia. 

On  bringing  an  object  close  to  the  eye,  especially  when  the  p\tpil  is 
movable,  the  circles  of  dispersion  do  not  grow  as  fast  as  the  size  of  the 
image;  even  though  it  be  not  so  distinct,  one  does  see  comparatively  good 
under  such  circumstances,  when  an  object  is  brought  very  near  to  the  eye. 
It  is  a  well-known  fact,  that  for  this  very  reason,  as  late  as  the  fifties,  high 
degrees  of  hyperopia  were  mistaken  for  myopia.  (Stellwag  and  Von 
Graefe).  That  a  large  percentage  of  the  cases  under  consideration  were 
hyperopic,  and  not  myopic,  is  apparent  from  the  fact,  that  vision  can  be 
improved  by  the  use  of  a  moderately  strong  convex  lens,  just  at  the  time 
that  a  cataract  is  developing.  Bonders,  (1.  c,  p.  190),  however,  draws  at- 
tention to  the  fact,  that  where  there  is  a  reduction  of  vision,  the  wearing  of 
a  convex  glass  is  seldom  of  any  benefit,  and  in  those  cases  where  a  beginning 
cataract  is  the  cause  of  the  disturbance  of  vision,  he  advises  especial  care, 
owing  to  the  frequency  of,  complications. 

For  the  more  recent  views  on  this  subject,  sec  (Chapter  IV.,  Part  I., 
page  60)  the  considerations  concerning  "'The  chainjc  in  the  index  of  re- 
fraction of  the  Jens.'' 

"In  cases  of  cataract,  the  power  of  accommodation  is  always  reduced, 
or  entirely  wanting.  This  is  not  entirely  dependent  on  the  fact,  that  the 
power  of  accommodation  is  always  reduced  in  the  aged  in  whom  cataract 
most  frequently  deve]o])s,  for  this  same  fact  is  almost  invariably  noted  when 
there  is  a  partial   or  stationary  cataract.     This  has  more  especially  been 


127 

found  to  be  tlie  case  in  zonular  cataract,  having  verified  this  years  ago  in  a 
series  of  examinations  conducted  by  Prof.  Schulek  and  myself.  (Becker). 
Even  young  individuals  who  have  zonular  cataracts  and  apparently  other- 
wise strong  and  healthy,  do  not  show  more  than  one-twentieth  of  the 
normal  amount  of  accommodation.  They  are  myopes,  though  slightly.  In 
just  such  cases,  Arlt's  explanation  would  seem  to  be  the  correct  one." 

"If  the  opacity  begins  in  the  centre  of  the  lens;  or,  as  one  is  wont  to 
say,  in  the  nucleus,  the  patient  will  see  less,  and  be  unable  to  differentiate 
objects,  if  he  looks  toward  the  light.  If,  however,  he  places  himself  at  the 
side  of,  or  even  turns  his  back  toward  the  light,  he  will  see  better.  This  is 
due  to  the  fact,  that  the  light  causes  the  pupil  to  contract,  hence  the  rays 
of  light  fall  directly  on  the  centre  of  the  lens,  just  where  the  opacity  is 
greatest,  whereas,  when  the  eye  is  turned  away  from  the  source  of  light, 
the  pupil  is  dilated  and  the  rays  of  light  fall  on  the  transparent  edge  of 
the  lens." 

"The  case  is  entirely  different,  where  the  opacity  starts  in  the 
periphery  of  the  lens.  In  this  case,  the  patient  sees  better  when  there  is  a 
narrow  pupil  and  in  a  bright  light,  and  worse  when  the  pupil  is  dilated, 
always  presuming  that  the  opacity  has  not  advanced  as  far  as  the  centre  of 
the  lens." 

"The  foregoing  paragraphs  are  taken  verbatim  from  the  work  of  J.  A. 
Schmidt,^^  published  in  1831.  This  is  true,  and  hence  the  oft-repeated  ad- 
vice to  use  atropine  where  there  is  a  beginning  cataract  is  not  always  a 
successful  practice.  It  is  not  at  all  an  infrequent  occurrence,  to  observe, 
that  where  the  pupil  is  dilated  in  order  to  allow  more  light  to  enter  the 
eye,  vision  becomes  more  indistinct,  and  the  patient  is  blended.  It  can 
easily  be  proven,  that  the  dilated  p\ipil  is  the  cause,  since  by  simply  placing 
a  diaphragm  in  front  of  such  an  eye,  sight  will  be  restored  to  its  former 
degree,  and  even,  in  some  cases,  improved." 

"According  to  the  investigation  of  Listing, ^^  there  are  met  with  in 
the  lens,  four  varieties  of  entoptic,  recognizable  and  distinct  objects  which 
are  constantly  present:  Pearl  spots,  dark  spots,  faint  striations,  and  dark 
lines.  Often  the  two  first  mentioned  are  in  all  probability  dependent  on 
cellular  formations  on  the  posterior  slirface  of  the  anterior  capsule;  the 
faint  striations  are  mostly  confined  to  an  area  corresponding  to  the  anterior 
lens  star.  The  dark  lines  are  supposed  to  be  dependent  on  a  thickening  of 
the  capsule  (?).  Therefore,  in  a  patient  in  whom  we  suspect  incipient  cata- 
ract, where  by  means  of  a  diaphragm  we  have  brought  these  objects  into 


32  Von  Amnion's  Zeitschrift,  I,  p.  345. 

33  Beltrag  zur  Physiol.  Oplik.,  184.5. 


128 

view,  we  are  enabled  to  decide  whether  or  not  pathological  opacities  are 
present  in  the  lens.  The  patient,  without  the  slightest  hesitation,  can 
draw  these  opacities  on  a  piece  of  paper  for  you.  By  having  this  done  re- 
peatedly, one  can  accurately  determine  every  increase  and  change  of  form 
which  these  opacities  undergo.  An  increase  nearly  always  is  accompanied 
by  a  proportionate  optometric  reduction  in  vision." 

"It  is  not  without  interest  to  note,  that,  800  A.  D.,  the  philosopher 
and  physician,  Leo,^*  makes  mention  of  the  fact  that  at  times,  during  in- 
cipient cataract,  mouches  volantes  appear.  Chapter  XXXIII.  reads  as  fol- 
lows: Trepi  v7roxvff£CD<::  oi  ds  toiovtoi  uar  apja?  ^Xettovgi 
jiODycoTTia  initio  culices  vident. 

"The  diaphragm  becomes  useful  in  another  way  in  diagnosticating  a 
beginning  cataract.  If  a  nuclear  cataract  is  present  and  the  pupil  is  not 
dilated,  the  diaphragm  will  materially  diminish  vision,  its  action  being 
similar  to  that  of  a  very  narrow  pupil.  In  cases  of  cortical  cataract,  vision 
can  often  be  markedly  increased  by  experimentally  moving  the  diaphragm 
about,  until  the  siiitable  area  is  found.  In  such  a  case,  the  light  passes 
between  two  cloudy  portions,  through  a  transparent  part  of  the  lens  to 
the  retina." 

"According  to  the  investigations  of  Von  Helmholtz,  (1.  c,  p.  141),  the 
polyopia  monocularis,  which  occurs  in  all  normal  eyes,  is  due  to  the  fact, 
that  one  may  imagine  the  lens  made  up  of  a  number  of  sectores,  which 
vary  slightly  in  their  index  of  refraction  and  hence  lead  to  slight  lateral 
displacements  of  the  various  images  against  each  other.  Monocular  poly- 
opia was  also  studied  by  Thomas  Young.^s  He  looked  upon  them  as  a  part 
of  the  entoptic  phenomena  due  to  irregularities  in  the  lens.  Helmholtz 
satisfied  himself,  by  experimenting  on  his  own  eye,  that  certain  light  and 
dark  striations  which  belonged  to  the  entoptic  pictures  of  the  lens,  grad- 
ually became  merged  in  the  light  and  dark  spots  and  striations  of  the  star 
figure  of  monocular  polyopia,  when  he  gradually  increased  the  distance  of 
the  diaphragm  from  the  eye.  In  beginning  cataract  we  also  find  objective 
recognizable  irregularities  of  the  lens,  hence  it  should  not  be  a  matter  of 
surprise,  if  this  polyopia  became  more  conspicuous.  Xot  infrequently  the 
very  first  subjective  symptom  of  beginning  cataract  is  this  phenomenon 
of  monocular  polyopia.  By  the  general  term,  'optical  irregularities,'  Helm- 
holtz fails  to  make  himself  clear  as  to  whether  he  really  means  irregulari- 
ties in  the  conditions  of  the  dioptic  system;  which,  however,  is  most  prob- 
ably the  case.  Such  irregularities  of  refraction  exist  in  the  lens  from  youth, 
but  owing  to  the  power  to  accommodate  accurately  these  slight  differences, 

34  Anecdota  Medica  Graeco  ed  Ermirius  Lugd.  Bat.,  1840.  p.  14G. 

35  Phil.  Trans.,  1801,  1  pi.  VI.  p.  40. 


139 

scarcely  make  themselves  noticeable;  hut  with  increasing  age  and  the 
gradual  diminution  of  the  width  of  accommodation  they  become  more  ap- 
parent, and  when  cataract  begins  they  become  not  only  more  numerous, 
but  the  inequalities  become  more  apparent.  Frequently  this  phenomenon 
is  due  to  the  reflexes  caused  by  the  opthalmoscopic  mirror.  Not  infre- 
quently the  real  cloudiness  of  the  -lens  is  preceded  by  a  stage  in  which  the 
lens,  so  to  speak,  is  fractured.  By  the  use  of  focal  illumination,  these 
fissures  and  splits  in  the  lens  reflect  the  light  and  appear  as  true  cloudy 
places,  very  similar  to  etchings  on  glass.  When  the  light  is  thrown  into  the 
eye  in  certain  directions,  the  same  phenomena  are  seen,  whereas  from  a 
somewhat  different  position  of  the  head  they  disappear  entirely.  Such  re- 
flecting surfaces  in  the  lens  must  of  necessity  be  followed  by  a  very  promi- 
nent polyopia." 

These  cases  were  classed  as  cases  of  irregular  astygmatism  due  to  thi.^ 
fracturing  of  the  lens;  they,  however,  did  not  know  that  such  a  fracturing 
of  the  lens  is  always  the  forerunner  of  the  formation  of  cataract. 

Becker  relates  a  most  brilliant  example,  in  an  individual  employed  as  a 
lamplighter  in  a  princely  palace.  The  patient  stated  that  in  the  evening  when 
he  would  light  the  side  brackets  and  the  central  chandelier,  he  would  see  thou- 
sands of  lights,  which  confused  and  frightened  him  to  such  an  extent  that  he 
began  to  imagine  that  he  was  bewitched.  After  this  condition  had  increased 
for  a  certain  length  of  time,  it  gradually  decreased  again:  in  the  meantime,  the 
cataract  continued  to  develop,  vision  gradually  being  reduced. 

Due  to  a  particular  arrangement  of  the  veils,  this  can  also  lead  to  a 
prismatic  deflection  of  the  rays  of  light  as  they  pass  through  the  lens.  On 
this  account,  occasionally  even  large  objects  appear  distorted,  bent  out  of 
position,  or  slanting.  That  such  a  formation  of  prisms  does  exist  in  the 
lens,  is  attested  by  the  fact,  that  in  a  certain  percentage  of  patients  in 
whom  cataract  is  developing,  the  complaint  is  made  that  the  light  is  sep- 
arating into  its  colors. 

Aside  from  this,  the  cloudy  striations  dissipate  the  light,  in  that  they 
act  like  corneal  opacities.  Totally  non-transparent,  partial  opacities  of  the 
lens  cause  disturbances  of  sight,  depending  on  their  position  and  in  pro- 
portion to  their  size.  Isolated  minute  punctate  spots  neither  hinder  a 
formation  of  a  sharply-outlined  retinal  image,  nor  do  they  absorb  sufficient 
light  to  make  a  diffuse  cloudiness,  A  saturated  cloudiness  may  reach  a 
considerable  degree,  and  if  in  the  axis  of  the  lens  (the  various  forms  of 
axial  cataract)  will  have  no  effect  other  than  to  dim  the  retinal  image. 

The  attempt  has  been  made  to  find  the  cause  of  congenital  nystagmus 
in  the  presence  of  this  axial  cataract,  but.  aside  from  the  fact  that  axial 


I30 

cataract  is  not  always  accompanied  by  nystagmus,  we  also  find  that  not 
infrequently  nystagmus  occurs  without  the  presence  of  axial  cataract.  It 
was  demonstrated  by  Amnion  and  Reuff  long  ago  that  it  is  not  necessary 
to  turn  the  eye  sideways  in  order  to  get  a  sharply-defined  image  of  the 
macula.    This  can  be  experimentally  proven  to  be  correct. 

Under  certain  conditions,  a  central  cloudiness  may  lead  to  a  spon- 
taneous appearance  of  the  "Purkinje-Arterial"  pictures.  Rente  (1.  cl.,  p. 
277)  relates  the  case  of  a  lady,  who  had  posterior  synechia  after  an  iritis; 
also,  cataracta  centralis  (spuria  (?).  If  light  entered  the  eye,  she  experi- 
enced a  sensation,  as  though  a  dark,  purple-colored  pane  of  glass  were 
placed  directly  in  front  of  her  eye,  on  which  there  seemed  to  be  a  large 
number  of  tree-like  figures,  which  she  compared  to  twigs  of  myrtle,  waving 
in  a  soft  breeze.  The  illuminated  capsular  cataract  (?),  acting  as  an 
original  source  of  light,  reflected  the  shadows  of  the  retinal  vessels  on  the 
posterior  layers  of  the  retina.  The  picture  was  produced  by  conditions 
similar  to  those,  where  by  means  of  a  lens,  the  light  of  a  candle  is  thrown 
on  the  outer  surface  of  the  sclerotic. 

Where  the  cloudiness  of  the  lens  remains  stationary,  vision  remains  the 
same  during  life,  or  is  subject  to  only  those  changes,  which  are  due  to  ad- 
vancing age.  Here  one  can  estimate  the  refraction,  width  of  accommoda- 
tion and  the  amount  vision,  by  the  usual  methods. 

The  same  must  be  done  in  cases  of  advancing  cataract,  with  this  dif- 
ference, however,  that  the  examination  must  be  repeated  at  intervals  of 
several  months.  These  repeated  examinations  give  us  an  estimate  as  to 
the  rapidity  with  which  the  cataract  is  developing.  Even  before  all  the 
cortical  substances  has  become  cloudy,  vision  for  smaller  objects  is  de- 
stroyed, (even  for  the  largest  test  type).  (Yaeger,  No.  24;  Snellen,  60). 
One  must  then  let  the  patient  begin  to  count  figures,  and  it  may  be  taken 
as  a  sign  that  the  lens  is  totally  opaque,  when  the  patient,  with  his  back 
toward  the  light,  can  no  longer  count  the  number  of  outstretched  fingers. 

It  will  always  remain  characteristic  of  the  disturbances  of  vision  due 
to  grey  cataract  that  the  perception  of  light  is  never  abolished.  A  cataract 
patient  should  always  be  able  to  recognize  both  qualitative  and  quantitative 
(color)  differences  of  incident  rays  of  light. 

The  lowest  degree  of  illumination  which  can  still  be  recognized  from 
absolute  darkness,  is  but  partially  dependent  on  the  character  and  forma- 
tion of  the  cataract,  but  in  reality  is  largely  dependent  on  the  condition  of 
the  retina  and  the  degree  of  its  sensitiveness  to  light.  Taking  this  factor 
into  consideration,  we  are  enabled  previous  to  an  operation  to  form  an 
estimate  as  to  the  degree  of  vision  we  can  expect  after  the  operation. 
Whereas  the  total  absence  of  sensation  to  light,  indicates  total  amaurosis. 


<,ne  is  enal.lcd  lo  drWvuuuv  l.y  \\w  ,l.-iv,.  ..f  .,imiitiniliv<'  |..'i-(Ti.ii..n  ^nt! 
light,  the  presence  or  ubsencc  of  moiv  or  less  imporlant  coinplical  ioii>'.  'i'o 
detoriiiiiu'  this,  it  is  nocessarv  to  cstitnatc  the  (l.'.urc.'  of  li-lit  perception.  lu 
former  limes,  one  was  satislied  to  simply  estimate  the  .sensitiveness  of  the 
retina  hy  watehin^-  the  reaction  of  the  pupil  when  an  eye  was  exposed  to 
various  stren.uths  of  light.  Another  metliod  was.  to  have  the  patient  rap- 
idly open  aud  close  his  eyelids  and  thus  watch  the  pupillary  reaction, 
thereby  gaining  an  estimate  as  to  the  sensit  iveiu-ss  of  the  ivtina.  This 
metliod  may  he  advise<l  today  where  the  [mpil  is  not  hound  down.  Kven 
in  a.  case  where  the  pupil  is  hound  down,  if  the  pupil  ot  the  other  eye  is 
free,  the  consensual  reaction  will  decide  tlie  ([uestion,  whether  or  not  there 
is  any  light  perception,  .\side  from  the  fact  that  in  old  people  the  action 
of  the  pui)ils  is  shiggish.  one  can  not  by  this  method  gain  an  idea  as  to  the 
degree  of  light  perception.  Hence  the  suggestion  of  Von  (Jraefe.  whicli 
appeared  in  the  first  volume  of  his  Archives,  (p.  328).  nnist  1)e  looked  upon 
as  a  great  step  toward  advancenienr.  His  method  was  to  examine  the 
patient  in  a  darkened  room,  and  let  him  decide  at  what  distance  he  could 
distinguish  the  light  of  a  small  lamp  or  candle;  also,  when  it  is  alternately 
covered  ami  nncoveivd.  'i'he  distance  af  which  he  can  distinguish  the 
light.  dei)ends  on  the  intensity  of  the  light  used,  on  the  construction  of  the 
cataract,  and  the  sensitiveness  of  the  retina.  In  order  to  obtain  results, 
which  should  be  estimated  on  a  basis  universally  employed,  it  became 
necessarv  to  construct  a  source  of  light  which  should  always  and  in  all 
places  have  a  given  strength.  The  same  result  could  be  obtained,  if  the 
distance  remaining  the  same,  the  intensity  of  light  could  be  changed  ac- 
cording to  a  measureable  scale.  This  course  of  reasoning  lead  Yon  Graefe 
to  construct  the  photometer. 

As  source  of  light,  a  wax  candle  of  known  thickness  is  used.  This 
illuminates  a  ground-glass  ([uadrant  over  which  two  metal  right  angles, 
with  the  angles  opposite  each  other,  glide  toward  each  other,  so  that  a 
quadrangular  figure  of  known  size  is  always  illnminat(>d.  Xot withstanding 
the  ingenuity  of  the  construction  of  this  a[)paratns.  owing  to  its  cost  and 
because  it  is  an  inconvenient  instrunicMit  to  handle  it  has  not  come  into 
genenil  use.  l"'or  [iractical  purjxises  it  suflices  to  examim'  the  light  sense 
of  all  cataract  |)atients  with  a  light  which  has  a  known  degree  of  intensity. 
A  lamj)  has  the  advantage,  that  one  may  increase  or  diminish  the  intensity 
of  the  source  of  light  by  turning  it  on  full  or  turning  it  down.  By  prac- 
tice, one  finally  gets  in  a  ])osition  to  be  able  to  make  a  useful  estimate.  This, 
however,  can  not  be  expressed  in  figures.  At  the  ])resent  day  the  argand 
burner  light,  as  used  in  making  opthalmoscopic  examinations,  is  used,  and 
gradually  turned  lower  and  lower  until  light   ]»ei-eeption  no  longer  exists. 


132 

The  lowest  degree  of  liylit  still  discernible  is  registered  as  smallest  lamp- 
light, medium,  or  bright  light.  As  indicated  above,  the  whole  examination 
is  only  then  of  value  when  vision  has  diminished  to  such  a  degree  that  the 
patient  can  no  longer  count  fingers.  In  certain  forms  of  total  cataract, 
this  in  fact  nevei-  occurs.  The  greater  a  nucleus  in  a  senile  cataract,  the 
thinner  consequently  must  be  the  amount  of  cortical  substance,  and  the 
farther  will  the  light  of  ,a  candle  llame  be  recognized.  The  character  of 
the  cloudiness  of  the  cortical  substance  likewise  has  its  influence.  If  this 
has  developed  slowly  so  that  the  general  cloudiness  and  radial  striations 
are  very  fine,  they  will  permit  more  light  to  penetrate,  than  the  rapidly 
developing,  cloudy,  mother-of-pearl  or  silky,  glistening  bluish-white,  wide- 
ly-striated cortical  substance.  In  such  forms  of  cataract  the  distance  at 
which  a  light  is  recognized  varies  from  20  to  30  feet.  In  fully-developed 
soft  cataracts,  in  which,  owing  to  youth,  a  real  nucleus  is  not  present,  as  a 
rule  the  light  sense  is  not  so  distinct.  In  this  form,  one  should  not  at  once 
judge  a  complication  on  the  part  of  the  retina  to  be  present,  even  if  the 
light  be  only  recognized  at  16  to  18  feet.  In  the  forms  of  fluid  or  emulsion 
cataracts,  as  well  as  in  the  cataracta  Morgagni  of  the  aged,  as  in  the  cata- 
raeta  lactea  of  youth,  it  may  happen,  that  the  light  disappears  at  8  to  10 
feet,  whereas  the  retina  is  found  intact  after  an  operation.  If  in  over- 
ripe cataracts,  after  a  time  the  swollen  cortical  substance  thickens  again 
and  becomes  more  homogenous,  the  distance  at  which  the  candle  can  be 
seen,  may  again  increase.  Under  certain  circumstances  this  becomes  a 
symptom  of  an  over-ripe  cataract.  In  exceptional  cases  it  may  even  reacli 
the  point  where  fingers  can  again  be  counted. 

Naturally,  calcareous  lenses  do  not  permit  the  passage  of  any  light. 
All  light  which  reaches  the  retina  must  pass  to  the  side  of  the  cataract, 
consequently  must  penetrate  through  the  sclerotic.  Even  though  the 
retina  were  still  capable  of  performing  its  function,  its  perception  to  light 
would  necessarily  be  of  a  very  low  degree.  But  cataracta  gypsea  and 
cakarea  are  almost  exclusively  found  in  amaurotic  eyes.  Von  Graefe  drew 
attention  to  the  fact,  that  occasionally  the  refraction  of  the  eye  exerts  an 
influence  (ui  tlie  results  of  these  tests.  High  grades  of  myopia,  when 
equip])ed  with  concave  glasses,  not  infrequently  give  the  differences  be- 
tween light  and  darkness  at  a  much  greater  distance  than  without  them; 
likewise,  the  hypero])ic  with  convex  glasses.  The  more  inexact  the  focus 
of  the  various  rays  of  light,  the  weaker  will  be  the  illumination  of  any 
particular  part  of  the  retina. 

Eye*  which  are  affected  with  non-complicated  cataracts,  can  decide  the 
color  of  the  light,  even  when  there  is  a  total  cataract.  The  perce])tion  of 
color,  however,  is  influenced  bv  the  color  of  the  muleiis.     if  the  nucleus 


133 
is  }-ello\v  or  hiowii.  llif  pcrcciMioii  (if  cDlor  will  he  ilic  siiiiic  as  in  a  healthy 
ove  lookiiiii'  llirmiii'li  vclhiw  nr  hiow  ii  i;lass.  Tlic  iiioi-c  intense  the  color  of 
the  nucleus  the  nioi'c  hlnr  li-lit  will  l»r  ahsoi-licd.  'riicivrorc,  if  a  cataract 
])alicnt  look>  lliioiiuli  a  eohall-hluc  ulass.  a  t'andie  tiame  will  appear  as 
violet.  ..!•  even  red.  The  same  will  follow  to  a  lesser  derive  if  the  patients 
look  ihi'onuli  a  hhie  .ulass  at  a  white  clond.  i')Ul  hy  nsiiifi-  glasses  of  other 
colors,  the  iiilluenee  of  the  yellow  nuelens  heconies  manifest.  A  bluisli- 
i^reen  ulass  appears  yellowish-^reen  to  him.  a  rv(\  .iilass  assumes  great  bril- 
liancy. If  one  shows  to  a  cataract  patient,  sheets  of  variously  colored  paper, 
(I'ach  of  a,  siiiiih'  coloi-).  every  answer  will  uo  to  ]trove.  that  he  sees  it  as 
thonuh  lookin.u'  throu^'h  a  yellow  .ulass. 

Tlierefore.  a  cataraetous  eye,  as  one  is  wont  to  e.\i)rcss  it.  lias  not  only  (luan- 
litaTiyc  lijjlit  sense,  but  is  also,  as  we  liaye  seen,  uot  without  perception  for 
•  inalit.v  of  incident  ra.vs  of  light.  Tlie  commonly  used  expression.  quulHative 
perception  of  lif/ht;  that  is.  the  recognition  of  objects  by  their  contour,  in  contra- 
distinction to  quantitative  percejition  of  light  used  to  designate  the  proper  exer- 
cise of  Judgment  dei)ending  on  Tlie  amount  of  light  which  penetrate  the  eye, 
should  hv  dropped,  since  it  not  only  gives  rise  to  a  misapprehension,  but  aside 
from  this  is  incorrect. 

Jf  one  will  nu)ye  his  hand  from  aboye  downward  before  a  cataraetous 
eye,  ^yhicll  no  longer  can  recognize  an  object,  if  no  complication  is  present, 
in  nearly  every  case  the  patient  will  be  able  to  perceive  the  direction  of  the 
motion.  This  will  at  once  be  evidenced  by  the  eye  following  the  hand.  If, 
instead  of  the  hand,  a  lighted  candle  is  used,  the  direction  will  always  be 
correctly  given.  The  examination  becomes  more  accurate,  if,  in  moving 
the  light  from  one  ])osition  to  another,  one  covers  it  with  the  hand,  be- 
cause where  the  perception  is  incomplete,  the  gradual  transition  from  one 
])lace  to  another  leads  to  conclusions,  whereas  the  perception  is  more  inde- 
pendent (for  each  jiortion  of  the  field)  where  the  light  appears  fir.st  in  one 
direction,  tlren  in  anothei-.  For  the  same  reason,  the  most  accurate  results 
ai-e  obtained  w  hen  the  light  is  reflected  fi'oni  the  various  directions  by  means 
of  the  opthalmoscopic  mirror.  It  then  liecomes  impossible  for  the  patient 
to  follow  the  light  from  one  position  to  another. 

From  this  experiment  it  beconjes  evident,  that  the  i)ower  of  projection 
of  light  of  the  eye  and  the  retina  is  not  impaired  by  the  cataract.  This  is 
explained  by  the  fact  that  the  cataraetous  lens  does  not  become  non-tran.s- 
])arent,  but  remains  translucent,  for  notwithstanding  the  fact  that  to  our 
eye  there  appears  to  l)e  a  com|)lete  (doudiness.  '•moleeidar  i)aths"  of  lens 
substance  still  remain,  through  whi(h  the  refracted  light  can  regularly 
pass.  ITence  the  cataraetous  lens  still  acts  as  a  collecting  lens,  does  not 
light  \\p  the  interioi'  of  the  eve  unifoi-ndv.  l)ut  concenirates  the   incident 


134 

rays  of  light.  (depeii(liii<;-  on  the  ])()siti()ii  of  tlu-  source  of  light),  on  a  par- 
ticular part  of  the  retina.  Attention  wa:-  drawn  above  to  the  fact,  that 
this  occurred  with  greater  accuracy  the  more  the  distance  of  the  source  of 
light  coincided  with  the  refractive  conditions  of  the  eye. 

If  now,  on  making  such  an  examination  with  the  candle,  one  finds 
that  the  patient  fails  to  locate  the  ])osition  of  the  light  in  some  particular 
portion  of  the  field,  or  if  lie  tails  to  locate  it  proj)erly  in  any  portion  of  the 
field,  one  concludes,  that  the  ])articular  ])ortion.  or  the  entire  retina  no 
longer  perceive  the  light.  On  can,  therefore,  notwithstanding  the  presence 
of  a  cataract,  diagnosticate  contractions  or  defects  in  the  field  of  vision.  On 
making  a  very  careful  examination,  it  becomes  possible,  and  \vith  a  con- 
siderable degree  of  accuracy,  to  map  out  the  form  of  the  defect  or  con- 
traction, so  that  it  further  becomes  possible  to  determine  whether  we  are 
dealing  with  a  case  of  glaucoma  or  a  detachment  of  the  retina. 

As  a  rule,  one  is  satisfied  to  determine  whether  the  peripljeiy  of  the 
retina  has  suffered,  since  this  complication  is  the  most  frequent.  How^ever, 
if  one  fails  to  examine  for  the  presence  of  central  defects,  this  may  lead  to 
unpleasant  disappointment,  when,  after  a  successful  operation,  one  finally 
comes  to  test  the,  vision. 

In  the  year  1871.  I  (Becker)  operated  the  prioress  of  a  convent.  Her  eye  had 
the  myopic  build,  and  she  said  that  she  had  always  been  myopic.  On  the  left 
eye  I  found  a  diffuse  posterior  cortical  cataract,  on  the  right  a  catanicto  (iccreta. 
The  examination  of  the  light  sense  and  projection  left  nothing  to  be  desii'ed. 
After  a  preliminary  iridectomie.  I  made  a  successful  extraction.  Nevertheless, 
the  patient  could  not  read.  Opthalmoscopic  examination  disclosed  a  large  de- 
fect of  the  retina  and  choroid,  wliich  undoubtedly  was  due  to  a  previous  hemor- 
rhage. A  special  examination  in  regard  to  tliis  condition  would  undoubtedly 
have  led  to  its  detection  before  the  operation. 

In  order  to  obtain  some  idea  as  to  the  size  of  the  snuillest  defect  which 
it  would  be  possible  to  detect,  notwithstanding  the  presence  of  a  cataract. 
Becker  attemjited  to  see  if  cataract  patients  could  hi'  made  aware  of  the 
presence  of  Mariottes'  spot.  This  was  shown  to  be  an  im])ossibility — hence 
ii  demonstratablc  defect  must  be  larger  than  tlu'  entrance  of  the  optic 
nerve,  'i'he  expei'inient  can  also  l)e  successfully  [tracticed.  by  testing  the 
distance  at  which  the  fiames  of  two  candles  will  heconie  fused  into  one. 
If  these  examinations  are  always  carried  out  with  the  candles  at  a  certain 
distance  from  the  eye.  one  can  obtain  (\\uiv  accural c  results  regarding  tlu> 
extreme  delicacy  of  the  perception  of  the  retiiui. 

••When,  after  the  above  method.-.  Ihci-e  i>  >lill  a  doubt  renuiining  as 
1o  the  light  sense,  oiu'  can  determine  h\  the  occasional  appearance  of 
phosplu'nes  ariuind  the  entrance  of  the  optic  iier\t'.  (more  detinitt'ly.  how- 


•35 

ovci-,  l)y  llic  |)i'c^ciic('  (.r  |.li(.>|)liciM's  as  sii<:,i:c>t(Ml  l)y  ScMc>  .!(■  I'zeo),  if 
there  is  aiiv  sensitiveness  of  the  retina  reinaininy  or  not.  'I'his  matter, 
however,  can  never  ,uain  any  pai'tieular  oi-  praetieal  valne."  ^^ 

AETI()L()(i^'  Ol''  ('A'r.\l.'.\("l\  In  the  previous  chapters,  taking 
senile  cataract  as  I  lie  prototype,  we  liave  cited  all  those  factors  which  lead 
to  tlu'  foi-niation  of  ealaraet.  We  have  seen  (pag.'  oO)  that  the  initial 
o))a('ities  are  due  to  ehenneal  changes  in  the  stagnant  fluid  which  occupies 
tlie  inters|)aces.  tlie  lihres  secondarily  becoming  cloudy,  due  to  their  chem- 
ical decomposition  and  niechatncal  disintegi-ation.  The  formation  of  these 
interspaces  being  i\\w  (page  Id)  to  interference  with  the  regular  sclerosis 
of  the  lens  and  to  mechanical  causes. 

"Where  both  lenses  become  cloudy,  one  at'tei-  tlie  other,  we  may  con- 
clude that  this  is  the  result  of  constitutional  disease.  Generally  speaking, 
one  nuiy  assume  that  the  fonnation  of  cataract  is  influenced  by  a  consti- 
tutional disease  or  diathesis,  especially  since  we  know  that  these  diseases 
may  lead  to  other  diseases  of  the  eye,  which  in  their  turn  lead  to  cataract,  as 
occurs  in  diabetes,  albuminuria  and  syidiilis.  However.  I  do  -not  wish  to 
be  misunderstood  as  stating  that  every  disease  of  the  eye  due  to  constitu- 
tional disease  will  eventually  lead  to  cataract.  In  his  "Pathologic  and 
Therapie,"  page  2'H,  Becker  states,  that,  strictly  speaking,  there  is  no  such 
thing  as  a  primai-y  cataract,  the  expression  "primary"  simply  hiding  our 
ignorance.  If  at  this  time  he  tried  to  locate  the  cause  in  the  eye,  at  the 
present  day,  though  we  still  seek  it  in  the  eye,  we  do  so,  in  an  altered  chem- 
ical constitution  of  the  vitreous,  which  influences  the  nutrition  of  the  lens. 
It  is  es])ecially  worthy  of  note  to  observe  whether  the  cataract  occurs 
in  both  eyes  or  not.  Where  the  disease  occurs  only  on  one  eye,  the  as- 
sumption is  a  perfectly  natural  one,  that  this  is  due  to  a  local  cause.  But 
in  those  cases  where  the  cataract  occurs  in  both  eyes  we  must  seek  for 
some  causative  factor  in  the  general  system,  even  for  the  cases  in  which 
the  eye  dist-ase  influences  the  nutrition  of  the  lens.  A  very  pregnant  ex- 
ample is  the  cataract  which  develops  in  retinitis  pigmento.sa.  The  occur- 
rence of  this  disease  in  several  members  of  the  same  family,  seems  decid- 
edly to  favor  this  hypothesis. 

Under  these  conditions,  it  does  not  seem  to  be  going  too  far,  to  assume 
a  like  cause  for  all  cases  of  cataract  which  occur  in  both  eye.s,  or  in  one 
shortly  after  the  other,  and  in  which  age,  togethei-  with  other  iieculiarities 
of  the  entire  organism,  play  a  ])r()niinent  part. 

"This  idea,  whether  t'onsciously  oi-  unconscionsly.  has  been   prevalent 

36Vgl.  v.  Graefe,  Klinisohe  Monatsblatter,  1865,  S.  140. 


136 

for  the  past  thirty  years.  Whereas  Sichel,  Vemeuil  ^"  and  Tesnier  ^s  con- 
fine their  remarks  to  attributing  their  poor  results  after  extraction  to  con- 
stitutional peculiarities;  others,  following  Mooren/9  have  attempted  to  find 
the  cause  in  a  previous  or  general  disease  existing  at  the  time  of  its  de- 
velopment. ]?ominee  *^  records  44  cases  of  cataract  on  both  eyes  in  youth- 
ful individuals,  their  average  age  being  thirty  years,  31  women  and  13 
men);  these  were  preceded  by  typhus  17  times,  variola  3,  chlorosis  and  loss 
of  blood  T;  purulent  discharges,  rickets  and  heart  disease  10.  These  few 
cases  do  not  give  these  causes  any  jjarticular  weight.  In  most  of  these 
cases  the  history  fails  to  state  whether  or  not  the  cataract  had,  or  had 
not  been  preceded  by  another  eye  disease,  which  in  its  turn  might  have 
led  to  the  cataractous  formation.  Kominee  designated  these  cataracts  as 
"cat  pointilee";  in  several  cases  as  "demi  molle.''  In  that  he  makes  the 
following  statement,  "gu'une  maladie  dibilitant  I'organisme  pent  prodnire 
la  cataracte,"  he  goes  a  step  further  than  Foerster,  who  states,*^  "IF  a 
cloudiness  of  the  lens  is  just  beginning,  very  severe  bodily  ailment  may 
hasten  the  development  of  the  cloudiness.  Dor^^  declares  that  all  cata- 
racts of  youthful  individuals  (occurring  in  both  eyes)  are  due  to  a  diathesis. 
In  eight  cases  he  found  phosphaturia  seven  times.  I  am  aware  that  the 
opinions  on  this  subject  are  very  conflicting,  and  it  is  quoted  here,  sinii)ly 
to  show  the  existing  desire  to  prove  that  cataract  formation  is  dependent  ou 
constitutional  causes.  Lately,  Deutschman  has  attempted  to  demonstrate 
an  actiological  connection  between  chronic  nephritis  and  senile  cataract." 

The  constitutional  disease  manifests  itself  in  its  action  on  the  lens  in 
such  a  manner,  that  it  either  first  causes  disease  of  other  portions  of  the  rifj, 
therehy  leading  to  a  pathological  changed  vitreous,  which,  in  its  turn  leads 
to  a  disease  of  the  lens  and  ratanut  formation,  or  the  hjnipJi  of  the  rn/ire 
organism  heconies  changed,  llrus  leading  to  cataract  formation  irlllioul  any 
other  disease  of  the  eye  having  .preciously  existed. 

"The  term  complicated  cataract,"  in  its  more  restrii-ted  sense,  is  used 


37  Note  sur  rOperiition  do  l.i  ('ntMiacto  cliez  les  l>iabtni(iii<"s.  Kcviie  tie  Med. 
et  Chir.,  1877,  No.  7. 

38  De  la  Phosphaturie  a  Forme  Diabotique  el  de  son  InHuonce  sur  le  Resultat 
de  quel  ques  Operations  de  Cataracte.    These  de  T^yoii. 

39  0pthalniiatr.  Beobaelitungen.    Berlin.  l.S(;7. 

40  Cataractes  ('onsecutives  a  la  tievre  Typhoid*'  el  .i  la  \ariole.  Recuell 
d'Opthal..  1S7J).  p.  .'S(;. 

41  Beziehunjien  dcr  AMiicinciii-Lcidcn  mid  <  )r.uaM-i:ikr;mmiii,m-ii  y.n  ^•rI•.•lIlder- 
unjren  nnd  Kraid<ii.'ilrn  <i.T  Schor^aiis.  <  Jr.icrc-S.i  iirs(  li  \U\..  \\\.  K;ip.  XIII. 
p.  231. 

42  Do  la  Cataracte  chez  les  I)iatliesi(iue.  Kev\ie  Mensuelh'  de  Med.  el  de 
<'hir..   bSTS,   J).  'A'22. 


137 

to  dosio-iiiitf  all  those  cases  ..I'  cnlara't  which  <lcvrl(.|.  in  cyc^  whii-li  liave 
had  a  previous  local  disease,  such  a>  a  detaeliiiieiU  oL"  the  retina,  absolute 
o-laucoma.  iiit  niotulai'  tumor  or  cv.M  icei-cus.  Here  also  ])eloni£  tliose  cases 
in  which  the  iris  has  hccoine  attached  to  the  capsuh-  of  the  lens,  or  where. 
I'ollowini:  an  irido-cvcliti>.  a  lu'u -I'oi  lueij  mehrane  i)econle^  attached  to  the 
])()stei'ioi-  surface  o\  the  len>.  In  all  the>e  caM'>  ahiiornial  eirculatory  con- 
dition.- are  developed.  'The  processes  of  secretion  and  assiinihition  take 
l)hu'e  uiuler  cliano-ed  condition,-.  The  local  cause  is  attested  hy  the  fact 
of  the  catai-act  reniainiiii;-  limited  to  the  one  eye. 

Of  all  the  forms  of  cataract,  those  easiest  to  understand  are  those  dm; 
to  ti-auma.  This  seldom  occurs  where  there  has  been  a  simple  concussion 
of  the  eye  without  luptui'e  of  the  capsule  and  consequent  jjathological 
entrance  of  the  fluids  of  the  eye.  Perhaps  these  exceptional  cases  can  be 
explained  in  this  way.  that  the  epithelial  lininp-  becomes  separated  from  the 
capsule  and  fails  to  become  adherent  a^ain.  If  the  suspensory  ligament 
tears,  the  lens  l)ecomes  luxated  and  comes  into  ditferent  relations  to  sur- 
rounding- parts.  The  capsule  coming  in  contact  with  solid  parts,  the  nutri- 
tive ])rocesses  are  interru])ted.  A  perfectly  analogous  result  follows  wheri 
.spontaneous  luxation  of  perfectly  transparent  lenses  occitrs.  This  last  con- 
dition, however,  is  the  result  of  some  previous  disease. 

If  the  capsule  is  ruptured,  the  dissolving  action  of  the  aqueous  and 
vitreous  is  made  luanifes-t  at  once  by  the  cloudiness,  the  swelling  and  the 
processes  of  absorption  of  lens  substance. 

CHAPTER  II. 

A  SYSTEMATIC  CONSIDEEATIOX  OF  THE  YAEIETIES  OF 
CATARACT. 

THE  MALFORMATIONS  OF  THE  LEWS. 

If,  as  formerly,  we  were  to  state  that  all  anomalies  of  the  lens  w^hich 
are  present  at  birth  are  congenital,  and  all  those  w'hich  develop  after  birth 
are  ac([uired,  we  would  simply  be  ignoring  the  underlying  causes  of  these 
conditions.  A  portion  of  the  abnormalities  can  be  traced  to  anomalies  in  the 
develo})ment  of  the  lens  and  the  eye:  another  portion  arises  after  the 
lens  has  been  fully  developed;  that  is,  during  the  foetal  period  of  growth 
in  a  manner  similar  to  analogous  diseased  conditions  which  occur  in  extra- 
uterine life,  in  consequence  of  pathological  conditions  of  the  entire  organ- 
ism, or  especially  in  the  eye.  There  is  simply  this  difference,  that  in  the 
former  we  must  conclude  from  the  residue  and  consequences,  whereas  in 


the  latter  case  we  are  in  a  position  to  make  direct  observation  and  to  follow 
their  course.  Thougli  they  are  congenital,  they  do  not  belong  to  the  mal- 
fomiations.  All  malformations  are  congenital,  but  all  congenital  diseases 
of  the  lens  arc  not  malfoi-mations.  Hence  the  congenital  diseases  will  be 
considci'cd  along  with  the  analogous  dist-ases  which  occm-  in  cxtra-ntcrine 
life. 

MALFORMATIONS    OF    THh:    LENS    SYS'iM<:M    WHICH    ARE    AS- 
SOCIATED WITH  ANOMALIES  OF  THE  HYALOID  AE- 
TERY  OR  THE  VASCULAR  CAPSULE  OF 
THE  LENS. 

Owing  to  the  important  role  whii-h  the  lens  takes  in  the  formation  of 
the  entire  eyeball,  the  mntnal  action  which  lens  and  globe  c^xert  one  on  the 
other  cannot  be  surprising.  In  a  whole  series  of  anomalies  it  is  ver^-  difli- 
cult  to  decide  whether  the  abnormal  process  in  the  development  of  the 
lens  influenced  the  formation  of  the  eye,  or  whether  the  interference  with 
the  development  of  the  eye  influenced  the  formations  of  the  lens. 

Anatomical  examinations  of  congenital  cataracts  have  for  some  time 
past  caused  attention  to  be  directed  to  the  fact  that  certain  forms  are  com- 
bined with  an  interrupted  retrograde  change  of  the  Avascular  capsule  of  the 
lens.  The  eolombata  of  the  eye,  in  whicli  most  pecrdiar  anomalies  in  the 
formation  of  the  lens  have  been  observed,  are  Hkewise  attributed  to  abnor- 
mal conditions,  those  of  the  arteria  hyaloidae  and  vitreous  playing  an  im- 
portant role.  We  are  indebted  to  Manz  ^  for  a  very  thorough  and  complete 
investigation  of  the  conditions  which  lead  to  these  anomalies.  From  these 
investigations  we  learn  that  the  invagination  of  the  epithelial  plate  into  the 
hollow  space  of  the  secondary  vesicle  may  give  rise  to  interference  with  the 
proper  closure  of  the  fissure  of  the  eye.  With  the  closure  of  this  fissure 
follows  a  complete  severence  of  tlie  communication  between  vitreous  and 
the  surrounding  ''head  jilate."  a  process  which  may  be  l)iit  illy  accom- 
plished, owing  to  the  advanced  stage  of  development  of  the  pedicle.  Above 
all,  Manz  reminds  us  of  the  blood  vessels  which  gain  entrance  along  this 
foetal  fissure  and  which  are  found  so  iibundantly  develojx'd  in  the  foetal 
eye.  This  is  attested  by  the  conditions  found  in  the  (ow  cases  of  colohoma 
hulbi  so  far  accurately  examined,  and  in  which  the  viiscular  system  of  the 
vi'treous  still  contained  the  branches  of  the  arteria  hyaloidea  extending 
from  the  walls  of  the  globe  to  the  capsule  of  the  lens. 

Whereas,  as  we  see,  ^Manz  seeks  the  primary  (au>e  in  an  excessive  vas- 

1  "Die  Missl)il<lniifit'ii  <lcs  Menscliliclicn   .\ii.iies."    (JrnetC  Saniiscli.   lid.   II.  2, 
Leipsij;,  1870. 


139 
cular  (U'volopnient  of  vcssi'ls  wliicli  vwiev  l'n»iii  the  iiiesudcnn,  Hess-  at- 
tributt's  this  to  an  oxccssivc  (lovclopinciit  of  connective  tissue  in  this  vascu- 
lar struct  inc.  Otlu'is.  auain.  as  Dcutschiiian.^  IToltzke/  and  Falchi,"  at- 
tempt to  lu-ovc  that  these  cojKhtions  an-  due  to  intrauterine  inflammation. 
In  liis  secoiul  contrihutioii  on  ihe  siihjet^t.  Tless  says.  "The  change  of  the 
foetal  coniu'ctivc  tissue  to  vitreous  liocs  not  take  phu-e.  so  tiiat  the  vascular 
foetal  coverino-  of  tlie  lens,  which  is  intimately  connected  with  the  former, 
since  the  development  of  this  tissue  is  retarded,  the  latter,  likewise  does  not 
keep  pace  with  tlu'  clian,i;es  in  other  parts  of  tlie  eye,  remains  behind  and 
the  secoiuhiry  vesich'  can  iu)t  (lose  properly;  sclera  and  choroid  are  not 
properly  developed  at  this  point."  Kverything  points  to  an  abnormal  de- 
velo])nu'nt  in  the  secondary  ocular  vesicle.  It  may  be  ditRcult  to  determine 
just  what  it  is  that  causes  the  .secondary  ocular  vesicle  to  fail  to  close,  but 
it  certainly  is  not  of  inilanimatory  origin. 

In  a  later  paper  by  lless,^  and  in  a.  recent  pidjlication  by  Ludwig 
Bach.'  the  position  is  taken  and  upheld  by  a  series  of  very  interesting  ana- 
tomical and  histological  examinations,  that  all  the  varieties  of  colobomata 
of  the  eye  are  due  to  an  abnormal  development  of  the  foetal  lens,  which, 
owing  to  its  abnormal  size:  interferes  with  the  proper  invagination  of  the 
mesoderniic  tissue,  destined  to  become  changed  into  vitreous,  thus  leading 
to  cases  of  so-called  anopthalmus,  oi'bitalcysts  or  micropthalmos.  The  de- 
layed retrogression  of  the  vascular  capsule  of  the  enlarged  lens  may  act 
as  a  mechanical  obstacle  to  the  entrance  of  mesodermic  tissue  at  any  point 
along  the  eipiator.  thus  causing  the  many  typical  cases  of  colomha  of  ciliary 
body,  iris  and  the  lens  itself.  The  cases  of  various  colobomata  along  the 
lines  of  the  ocular  fissure  are  ex])lained  as  the  result  of  failure  of  the  fisstire 
to  close  at  the  proper  time,  either  as  the  result  of  an  abnormal-sized  lens, 
a  failure  of  vitreous  to  differentiate  at  the  proper  time,  or  of  blood  vessels 
too  actively  developed,  and  which  fail  to  retrogress.  Though  inflammaitory 
causes  are  not  denied,  they  are  not  looked  upon  as  the  usual  cause. 


2Zur  Pathotrenese  des  IMieropthalmus.  Arch,  fur  Opth..  Vol.  XXXIV,  Bd.  3. 
1888,  and  "Weitere  uutersnchuugen  uber  anjreborene  Missbildungen  des  Auges. 
Graefe  Arch..  Vol.  XXXVI.  B.  1,  1890. 

3  Zur  rathologische  Anatomie  Iri.s  und  .Vderliaut  CololKniia:  also  (Jrundlage 
eines  Krklarnujisversuchs  der  sogenante  lleiininuiiisliildun.Lr  nhtM-hani>t.  Klin- 
ische  :M()natsl)latter.  XIX.  p.  101. 

4  "Mickroptlialmus  und  Colobouiaiii  Kaninclieii."  Ai'<li.  fur  Augenheilkunde. 
XII. 

5"Mi('rofthalmo  Congenitn."    Annal  di  Ottaniologia.  XIII.  1888. 

6  ■'Pathologische  Auatoniische  Studien  uber  einige  soltene  angeborone  Miss- 
bildimgeu  des  Auges,  etc."    Graefe  Arch..  Vol.  XLII.  part  III.  ISOC. 

7  "Path.  Auat.  Studien  uber  verscliicdeiie  Missltildungeii  des  .\uges. "  (Jiaefe 
Arch..  Vol.  XLV.  part  I.  1808. 


I40 

THE  COXDITIO.N   OF  'i'JlK  LKNS  IX  CASES  OF  AN0PTHAL:V[US 
AND  :\II('R()PTIIALMrS. 

]1  would  scarcely  seem  iiecessarv  to  state  that,  wlierc  the  eye  is  absent, 
the  lens  must  also  be  absent,  if  it  weiv  not  for  the  fact,  that  the  word 
'annpihalmvs:  originated  ])y  Adam  Scliinidt.'^  is  used  to  designate  a  mal- 
formation of  the  eye  wliere  an  ahnonnally  small  and  poorly  developed  eye 
is  present,  which  does  not  push  tlie  coujimctival  sac  forward  in  the  usual 
manner,  but  rather  lies  behind  and  heh.w  the  conjunctiva.  It  is  in  Just 
such  eves,  whicli  belong  to  tlu'  m irnipllidhii us  and  rnjohnma  toiuli  nculi 
(Arlt)  class,  that  we  tind  the  lens  or  its  aiiah.gui'  in  phices  where  we  least 
expect  to  find  it. 

In  his  Anatomie  and  Pathologie,  page  l-^(i,  Becker  states:  '-The  fre- 
quently described  cases  of  cysts  behind  the  lower  eyelid  are  always  found  in 
cases  where  there  is  a  rudimentaiy  eye.  The  gradually  developing  sac-like 
process  springs  from  the  sclerotic,  owing  to  inadequate  closure  of  the 
ocular  fissure  in  cases  of  highly  develo])e(l  choroidal  or  optic  nerve 
coloboma.  To  how  great  a  degree  the  vitreous  and  the  vessels  of  the  optic 
nerve  are  implicated  in  the  formation  of  this  anomaly,  can  not  be  decided 
in  tlie  individual  case.  Jt  is.  however,  a  fact  that  in  many  cases  of 
'}iiicyi)j)lliubitus  and  so-called  (utopthdUinis.  llic  colohotint  onill  Intnlc  of 
Arlt,  the  lens  or  its  rudiment,  is  still  in  contact  with  the  retina,  or  is 
posteriorly  held  fast  by  the  arteria  corpus  vitrei,  and  anteriorly  in  contact 
with  the  iris  by  means  of  the  vascular  memhrane  of  the  ])upil.  The  in- 
verted pujDillary  edge  of  the  iris  is  always  abnormally  removed  from  its 
proper  ))osition.  It  is  the  rule,  to  tind  a  portion  of  the  hyaloid  artery,  and 
at  least  a  ])ortion  of  the  vascular  capsuU'  of  llie  lens  ])ersisting." 

"Examination  of  an  eye  in  whicli  the  lens  was  adherent  to  the  optic  nerve 
showed  that  the  lens  Avas  a  round  body  made  up  of  variously-formed  large 
cells  surrounded  by  vascular  villi.  The  lens  was  in  a  condition  analogous 
to  that  of  the  Second  Period  of  I)eveloi)ment.  This  period  corresponds  to 
the  time  when,  under  normal  conditions,  the  vessels  and  the  vitreous  begin 
to  extend  into  the  eye  along  the  fissure  in  the  optic  nerve,  getting  in  be- 
tween retina  and  lens.  Whei'e  the  lens  is  found  in  tlu'  centre  of  the  vitreous 
in  a  case  of  micropthalmus.  it  is  found  to  l)e  smaller  than  under  normal 
conditions,  ilowevei-.  it  does  ha|)i)en,  that  notwithstanding  the  persistence 
of  the  connection  hetwceii  the  hyaloid  artery  and  the  branches  of  the  ves- 
sels of  the  meinhraiu'-|)U|)illai-is,  its  development  is  ecpial  to  that  of  the 
lens,  at  the  end  of  the  foeial  pei-iod  of  growth. 

In  the  a1)o\c-(niotc(l  papei'  of  Ilach.  he  states: 

■^'Owing  to   the   prolonged   period   of  time  during  which   the  lens  fills 

SHiiiilv  and  Sdiiiiidt  Optli.  Bibl.,  Ill,  1,  S.  190. 


141 
6ut  the  iiiicrioi-  of  the  i^]o^)v.  tlic  vitivous  docs  iiol  dcvcloi.  ;il  llic  |. roper 
time,  jullu'sioii  l)(.'t\v('('ii  iiu'sodciiiiic  tissiu'  aloii^-  the  ocidai-  H.-.-iirc  and  Ih^ 
foetal  vascular  capsule  of  the  lens  arc  not  separated,  and  as  tlic  iuuuediate 
result,  the  retinal  lissure  does  not  close  properly — as  a  natural  residt,  the 
other  coverin.us  of  the  ^lolx'  alony-  its  under  side  are  inllucnccd  and  re- 
tarded in  tlieir  or,,\vth.  One  can  well  sec  how.  as  the  result  of  the  size, 
altered  and  swollen  structure  of  the  lens,  and  fnrth.'r  as  the  result  of  the 
hindrance  to  the  separation  of  the  vascular  capsule  of  the  lens,  from  the 
surrounding  mesoblast;  this  can  lead  to  an  inei-ease  of  intra-ocular  tension, 
in  consequence  of  which,  the  defective  lower  wall  of  the  eye  in  its  entirety, 
or  only  at  one  point,  gives  and  becomes  excavated."  If  this  condition  is 
long  continued,  it  may  lead  to  a  total  colond)a  oculi.  and  an  orhital  or  sub- 
conjunctival cyst.  At  times,  the  action  ceases  after  a  time  and  tlie  very 
small  micropthalmic  eye  is  connected  by  a  pedicle  with  a  very  line  lumen, 
with  the  cyst  proper. 

Jn  his  Therapie  and  Pathologic.  Section  52,  liecker  states:  "rp  to 
the  present  time,  a  malformation  of  the  eye  consisting  of  a  total  absence 
of  the  lens  has  not  been  observed,  and  considering  the  part  the  lens  plays 
in  the  formation  of  the  embryonic  eye,  it  surely  will  be  a  difTicult  matter 
to  ex]ilain.'"  Dr.  Carl  Hess,  (Beschreibung  des  Auges  von  Talpa,  luiropaca 
nnd  vo]i  Proteus  Aiiginens  Graef  Arch,  Vol.  XXXV.,  B.  3,  LSS9).  as  th^' 
result  of  his  studies  of  rudimentary  eyes,  states  that  *'the  indenting  of 
the  primary  vesicle  is  not  caused,  as  is  so  universally  taught,^  by  the  in- 
dipping  of  the  lens,"  and  it  is  especially  interesting  to  note  this  fact,  since 
H.  Becker  10  came  to  the  same  conclusion  by  an  entirely  ditfei-ent  roitte. 
since  he  had  the  opportunity  of  examining  a  micropthalmus  (with  a  total 
indipping  of  the  ocular  vesicle),  in  which  there  was  a  total  absence  of  a  de- 
velopment of  the  lens."  Kolliker  likewise  believes  that  it  is  possible  for 
the  primary  vesicle  to  be  indented,  without  the  presence  of  the  ectoderm. 
In  a  later  paper,  Hess  once  more  draws  attention  to  this  fact.^^ 

He  describes  a  eliick  120  hours  old.  wliicii  lind  Ix'cii  (lcv<'lo])C(l  in  an  incu- 
bator. The  left  eye  avus  perfectly  developed,  whereas  on  tlie  ritrlii  side  perfect 
anopthalmus  existed.  Examination  showed  tliat  tliere  was  noi  even  an  out- 
growth of  the  primary  optic  stalk  from  tlie  brain;  excludin.uc  a  theory  of  develop- 
ment with  subsequent  loss  as  the  result  of  disease.    Tlie  microscopical  examina- 


9  Schwalbe  Lehrbuch  der  Anatomic  des  Auges. 

10  Ein  Fall  von  Micropthalmus  congenita  uniliteralis.  nebst  einigen  Bemer- 
kiingen  uber  die  vermutleielie  Aetiologie  und  Entwickelungs  geschichto  dessel- 
ben.  Graefe  Arch.,  XXXIV,  B.  3.  ISSS. 

11  Beitrage  zur  Keuntniss  der  ratliologischen  Anatomie  der  Angelmieuen 
Missbildungen  des  Auges,  Graefe  Arch.,  Vol.  XXXVIII.  B.  3.  92. 


142 

tion  proved  all  of  this;  also,  the  absence  of  a  sign  of  the  lens  on  the  right  side. 
This  is  undoubtedly  a  phenomenon  of  the  greatest  interest,  and  should  be  re- 
membered when  wo  try  to  study  the  relations  between  the  development  of  the 
eye  and  lens. 

Ill  this  saiiK-  |);ii)('r  he  reports  a  case  of  cyclops,  (in  a  pijr),  ihe  single 
eye  containing  Uvo  'perfectly-formed  lenses.  So  far  as  I  liave  been  able  to 
discover,  this  is  the  only  ease  of  tlie  kind  reported  in  literature.  Hence  I 
will  (I note  it  in  full: 

"The  specimen  was  sent  t(t  iiic  iCarl  Iless)  by  Dr.  Ruge.  of  Amsterdam. 
The  single  eye  was  placed  just  abovt>  the  very  prominent  snout.  The  eye  was 
almost  globular  in  shape,  and  had  a  diameter  of  22  mm.  The, almond-shaped  lid 
fissure  was  about  27  mm.  wide.  It  was  impossible  to  detect  a  line  along  which 
there  had  taken  place  a  fusion  of  tli<>  lids.    Puncta  lachrymalis  wanting. 

The  cornea  was  transversely  oval,  and  disclosed  a  slight  depression  in  tlie 
center,  likewise  above  and  below  the  edges.  These  indrawn  places  were  con- 
nected by  a  very  fine  vertical  line,  so  as  to  give  the  impression  that  along  this 
line  the  two  cornea  had  joined.  Both  halves  were  of  equal  size;  their  total  di- 
ameter equal  to  17  mm.  Otlierwise,  one  tinds  no  signs  suggestive  of  two  eyes 
being  joined  togetlier.  On  dissecting  the  eye,  find  but  a  single  optic  nerve,  and 
transverse  serial  sections  appear  normal.  The  retina  is  detached,  but  shows  no 
evidence  of  separation  into  tAvo  halves.  In  the  anterior  half  of  the  eye  the  con- 
ditions are  somewhat  more  complicated,  owing  to  the  presence  of  tiro  letifies. 
One  finds  two  perfectly  developed  lenses,  situated  about  4  mm.  from  each 
other.  liaterally,  from  each  is  a  normal  ciliary  body,  and  a  normally  developed 
iris.  Corresponding  to  the  vertical  tine  line  on  tlie  external  surface  of  the 
cornea  there  appears  on  its  posterior  surface  a  T  formed  iirouiinence,  looking 
upward  and  downward.  This  prominence  is  smallest  at  the  center:  tlius  form- 
ing for  each  lens  a  pupil  of  about  normal  size.  These  prominences  consist  partly 
of  vascular  connective  tissue.  p;utly  of  nonstriated  vascul.ir  tibres.  like  those 
found  in  the  ciliary  body.  The  prominence  which  extends  backward  is  covered 
Avith  a  thick  pigment  layer  of  epithelial  cells,  as  seen  on  the  p.irs  ciliaris  retinae. 

Tlie  anatomical  conditions  of  the  brain  were  especially  interesting.  On  re- 
moving the  calvarium.  the  cerebellum  and  corpora  quadrigemina  were  found  to 
be  normal.  At  the  anterior  end  of  the  brain  the  cerebrum  appeared  as  an  un- 
divided mass,  filling  up  the  anterior  fossa  completely,  but  only  altout  one  <iii. 
in  thickness.  As  a  result,  the  corpora  (luadrigeninui  Avere  completely  uiicov(>re<l. 
The  upper  surfac<'  showed  a  number  of  shallow  dci»rcssions,  but  no  real  sulci 
or  convolutions.  Tlio  mass  lying  anteiior  to  tlic  coiiioia  (niadrigeiiiiiia  was  only 
connected  Avitli  the  latter  Ity  a  very  thin  laiiiolla  of  nervous  tissue.  The  pos- 
terior margin  of  this  single  si)liere(l  (•ereitriiin  was  covered  liv  the  pia  in;iler. 
from  which,  on  both  sides  of  the  median  line,  a  small  choroidal  jilexis  had  de- 
veloped. On  iii:ikiiig  ;i  frontal  section  through  the  center  of  this  cerebrum,  a 
very   tine    iiorizont:il    fissure,    which    .-iiijieared    to   communicate    with    the    third 


'43 
vfiitriole  \v:is  disoovoi-od.  TIh-  r(.ll(.\\iii^;  ((iiHlitiinis  were  ro\iii<l  .-ii  llw  liaso: 
The  luiddle  and  posterior  portions  of  tlic  l)raiii  wcrr  aiipar.-iitly  iiDiiiialiy  de- 
veloped. The  position  of  tlie  cpli*'  irads  and  <liiasiii  was  (.crupird  l.y  a  single 
niedianly  placed  urvw.  which  anlfriorl.v  iiasscd  tinou-ii  ilir  siii-lc  optic  for^ 
amen.  Posterior  to  tlic  optic  iicrvc.  at  tlic  itasc  of  liir  I. rain,  a  siiiL'lc  corpus 
iiianiillarae  was  found:  oculomotorins,  trocidcaris  and  alxiuccus  were  all  ar- 
ranged double.  A  very  <h'licatc  furrow  runninji  aioii;;-  tin-  luidcr  surface  of  tiie 
brain,  was  tin-  only  indication  of  a  division  of  tlic  ccrcl>nini  into  tw(»  iicuiis- 
l»iieres.  Tlie  exact  condition  of  the  olfactory  nerve  could  not  Ite  «h-linitely  de- 
termined. 

Accordins;ly.  the  posterior  and  middle  portions  of  Die  liraiii  were  normally 
develoi)ed;  whereas,  the  cerebrnm  and  all  tiie  parts  wiruii  <levelop  fiom  it,  the 
olfactory  and  optic  nerves  and  retina  weic  developed  as  a  single  one.  wliereas-, 
tJie  portu  of  the  eye  Orvcloitrd  fniiii  the  irtodcnii  ircrr  iigain  double.  It  is  indeed 
astonishing  tliat  no  signs  of  ftision  can  be  noted  on  tlie  eyelids. 

Tlie  alt(Mii[)t  has  hceii  iiiadc  to  explain  the  roriiiatioii  oF  cyclopic. 
ITushkc  assiiiiR'd  that  it  was  dtic  to  an  aljiioniial  or  iiicoiiipletc  division  of 
the  general  ocidar  germ.  According  to  this  view,  c}'elopic  would  be  a  true 
interference  in  development.  Opposed  to  this  view  is  that  of  Merkel,  Geof- 
frey, Saint  Tlillairc  and  others,  who  assume  that  the  cyclopic  eve  is  the 
result  of  a  fusion. 

irately,  Dareste  has  conceived  a  view  which  leans  toward  that  of 
Husehkc.  According  to  his  view,  the  cyclopii'  is  due  to  an  interference  in 
the  development  of  the  anterior  cerebral  vesicle,  which  is  due  to  an  abnor- 
mally, early  closure  of  the  vesicle.  Hess  states  that  he  can  hardly  join  tlie 
one  view  or  the  other,  but  emphasizes  the  fact,  that  this  case  is  more  easily 
explained  as  the  result  of  an  interference  in  development,  rather  than  on 
the  hypothesis  that  this  is  due  to  a  fusion  of  two  originally  separate  organs. 

(JATAKAfTA  MKMRKANAOEA  CONl^KN IIW    .VCCHETA. 

In  18()1,  Wilde  ^-  drew  attention  to  the  fact  that  some  of  the  forms  of 
congenital  cataract  are  associated  with  anomalies  in  the  retrogressive 
changes  of  the  hyaloid  artery,  resjvcclivcly,  the  vascular  capsule  of  the  lens. 
Becker  described  the  examination  of  such  a  ctitai'act  as  follows:  'i  ex- 
amined such  a  cataract  and  found  a  wavy,  folded  ca]>sulc  of  normal  thick- 
ness and  transparency:  also  a  well-preserved  single  layer  of  epithelial  cell-: 
aside  from  these,  very  regularly  arranged  lihre-like  cells  extending  from  be- 
hind forward,  showing  beautifid  nuclei,  in  the  at^piatorial  region  in  the 
situation  of  the  lens  whorl  were  found  disintegrated  masses.     On  the  ex- 


12  Congenital   diseases  and    malformations   of   tlie   dioi)tr.    media.     iMinlin's 
Quarterly  Journal,  No.  61,  IStil. 


144 

ternal  surface  of  the  posterior  tapsule  were  found  numerous  patent  l)loo(l 
vessels.  These  conditions  are  exceedingly  interesting,  because  they  indi- 
cate that  the  cause  of  the  disease  could  not  have  exerted  its  influence  long 
after  the  beginning  of  the  third  period  of  foetal  development.  This  must 
coincide  with  about  the  second  month  of  foetal  life."  (See  Manz.  page  82). 
The  persistence  of  the  hyaloid  artery  places  this  malformation,  which  may 
"be  designated  as  a  failure  of  the  lens  to  undergo  further  develoi)ment  after 
having  reached  a  certain  stage  of  development,  in  the  category  of  the  above- 
described  sequelae  of  coloboma  formations.  A\'.  von  (Irollman  ^"  describes 
a  case  in  which  the  posterior  capsule  was  wanting,  the  hyaloid  artery  had 
grown  into  the  lens,  which  was  filled  with  connective  tissue,  blood  vessels 
and  a  few  lens  fibres. 

The  fact,  that  branches  of  the  hyaloid  artery  still  containing  l)lood 
are  found  on  the  posterior  surface  of  a  certain  class  of  congenital  mem- 
branous cataracts,  indicates,  since  the  hyaloid  artery  has  no  accompanying 
vein,  that  a  number  of  venous  branches  of  the  vascular  capsule  also  re- 
main. And,  as  a  fact,  in  this  form  of  cataract  one  does  frequently  find  that 
a  connection  between  the  capsule  and  the  iris  still  exists.  Hence  this  form 
is  also  designated  as  rahinicfd  niniihrdiHircn  roitjcin'la  acciria,  in  that  this 
connection  is  looked  \\\)nu  as  a  jiosterior  synechia,  the  result  of  a  foetal 
iritis.  Further  anatomical  examinations  of  entire  eyes  containing  cataracta 
membranacea  .accreta  are  necessary  in  order  to  show  whether  there  are 
other  remains  of  a  foetal  iritis.  This  touches  on  the  question  of  the  cause 
of  the  membrana  pupiUaris  perseverans  and  the  deposits  on  the  outer  sur- 
face of  the  anterior  capsule  which  thus  leads  to  the  cafarada  capsularis  an- 
terior s/niria.  It  ispossiblethata  disturbance  in  the  retrogressive  change  in  the 
vascular  capsule  is  to  be  sought  in  an  inflammatory  proct'ss  in  this  capsule. 
This  would  also  explain  the  genesis  of  the  cahiniclti  /xilnris  posterior  spuria. 
All  the  cases  so  far  described  are  deposits  on  the  outer  surface  of  the 
posterior  capsule  and  usually  are  found  in  the  region  of  the  posterior  ]iole 
of  the  lens.  They  are  chai'acterized  by  the  white  shining  color  which  this 
form  of  cataract  reflects.  It  is  seldom  very  small,  often  the  size  of  a  hemp 
or  poppy  s(>ed,  and  fre(piently  by  focal  illumination  one  can  see  that  an- 
teriorly it  is  concave  and  smooth  as  a  mirror.  On  using  the  oi»tlialmoscopc 
it  can  be  seen  to  taper  toward  the  xitreous.  (ieiu'i'ally  its  contnur  is  round, 
though  in  the  individual  case  it  may  show  a  few  pointed  striations. 

It  might  possibly  he  mistaken  for  a  posterior  cortical  cataract  such  as 
occurs  in  choroidal  disease  and  disease  of  the  vitreous,  more  particularly 


13  "Uber  Mickropllialiims  mu\  (':itiii:ictM  ('(Hiycnil;!  VMseulosM."    (Jraef  Arch. 
Vol.  XXXV.  B.  314.  ISS'J. 


'45 

(lie  form  .K-ciiiTin,<:-  in  ivtiiiili-  |)i.-inciU..~ii.  It  i^.  Ik-wcx  .t.  ikiI  (lilli.-ull 
lu  (lii1\Mviitialc.  since-  in  [...stciior  cnrticnl  calai.iri  tlio  glistening  white 
color  and  niirror-likc  sniootlnu'ss  arr  wantinp-.  and  llir  latter  form  generally 
goes  over  into  the  general  eortieal  eatarael  wliih'  under  ohservation.  The 
presence  of  radiating  sti-iae  favors  the  diagnosis  of  posterior  conical  cata- 
ract, on  till-  ontei'  >urfa(H'  td'  the  ])o>terior  capsule. 

A'on  Amnion'^  \\a>  the  lii'st  lo  draw  attention  to  the  fact,  that  ab- 
normalities at  the  posterior  capsule  could  he  traced  to  disease  of  tlie  hya- 
loid, in  the  eve  of  a  rahhit  hoin  hiin.l,  lu'  f.umd  the  ol)literated  central 
artery,  logetlu'r  with  a  ceiiti-al  ojjacity  of  the  posterior  wall  of  the  capsule, 
lie  gives  an  illustration  (Fig.  Ti.  Plate  15)  of  a  ease  of  congenital  thick- 
ening of  the  hyaloid  artery  and  a  resulting  cataraeta  centralis,  showing  a 
portion  of  the  artery  attached  ])osteriorly  to  the  conical  lens,  through  the 
axis  of  which  an  opacity  exists.  \'on  Amnion  diagnosed  opacities  in  the 
posterior  portion  of  the  lenses  of  living  men,  which  he  ascribed  to  early 
(d)literation  of  the  centi'al  arteiT.^''  11.  Muller  (I.  c.  p.  SC.)  described  such 
a  posterior  i)olar  catarat-ta  in  both  eyes  of  a  goat.  l>oth  lenses  showed  a 
two-fold  cloudiness.  He  also  observed  a  case  in  which  there  was  a  greyish 
opacity  in  the  centre  of  the  lens,  [rataracla  centralis),  together  with  a  flat- 
tened cone  at  the  po.sterior  surface,  yellowish  in  its  centre,  yellowish  white 
at  the  periphery  and  ])rotrnding  backward  through  the  vitreous  to  the 
papilla:  from  the  ci'Utre  of  this  cone  the  hyaloid  artery  could  be  seen. 
The  eyes,  though  of  normal  shape,  showed  the  evidences  of  a  |»revious  iii- 
flanunatory  infiltration.  The  central  artery  was  sui'rounded  hy  iidlam- 
niatory  jn'oducts  and  could  be  distinctly  seen  to  pass  between  the  nodule 
and  the  lens  substance.  Therefore,  the  opaque  mass  had  its  seat  at  and  in 
the  remains  of  the  embryonal  capsule  of  blood  vessels,  and  it  can  scarcely 
be  doubted  that  this  peculiar  formation  is  due  to  an  interference  with  the 
embryonal  development  of  the  oi'gan.  Finally,  we  are  indebted  to 
Berthold  ^''  for  the  exact  exannnation  of  such  a  cataract,  obtained  from  a 
congenital  buphthaliuus.  and  the  origin  of  which  he  likewise  traced  to  a 
persistent  arteria  ca])sidaris.  Jle  found  beautiful  e])ithelial  cells  ahmg  the 
posterior  cap.sule,  the  lens  otherwise  being  jierfectly  noi'inal.  lie  adds.  "It 
is  remarkable, that  this  epithelium  which  is  found  alongthe  po>ti'rior  cajisule 
dm-ing  foetal  life  should  not  have  entirely  disappeared,"  but.  according  to 
our  understiinding  of  the  subject   today,  this  e])ithe]iiim  must   have  been 


14  Klin.  Darstollun?-.  III.  p.  (u. 

l->8ee  also  Recli.  "Do  ("atarada  ("cnli-.ili."    Iiimul;-.  Dissert.  Lips.  18.".0. 
16  "Beitraji-  znr  Pathol(),s.nscli("  Anaroiiiie  «les  Au.-e."    (Jraefe  Arch.,  Bd.  XVII, 
1)   174,  1871. 


146 

newly  funned.  Thif^  would  then  bo  tlie  first  and  only  case  in  which  such 
a  newly  formed  epitlioliuni  was  found  in  a  transparent,  non-eataractous 
lens.  Berthold's  observations  become  still  more  interesting  since  Becker 
(Anatomic,  p.  TO)  observed  a  like  condition  in  both  lenses  of  a  dog,  but  he 
is  nnable  to  give  a  satisfactory  ex])lanation.  A  later  observation  and  ex- 
amination l)y  Oeller,!'^  in  the  case  of  a  boy,  also  one  in  the  eye  of  a  pig, 
here  noted,  are  certainly  worthy  of  being  read. 

Since  attention  has  been  directed  to  this  subject,  the  opthalmoscopic 
examination  lias  disclosed  very  fine  foetal  remains  of  the  hyaloid  and  its 
brandies,  sucli  as  cause  no  interference  with  sight  and  which  ordinarily 
Mould  have  been  overlooked. 

Cww  Report.  Miss  K.  S.,  aged  18,  came  to  have  her  eyes  tested  iu  November. 
1895.  Opthalniosoopic  examination  of  fundus  disclosed  a  somewhat  irregular 
heart  sliaped  choroidal  atrophic  area  to  the  upper  and  slightly  to  the  nasal  side 
of  the  papilla.  This  area  is  snow  wliite.  surrounded  by  a  deeply  pigmented 
margin,  and  about  the  size  of  the  papilla.  During,  the  examination  a  peculiar 
striafion  seemed  to  veil  the  distinct  view  of  the  fundus,  but  on  gradually  adding 
plus  glasses,  until  the  posterior  surface  of  the  lens  was  accurately  focused  (plus 
10  D).  these  striations  gradually  became  distinctly  visible  as  black  lines.  They 
take  their  origin  from  a  knob-like  protuberance,  Avhich  curves  backward  into 
the  vitreous.  It  passes  on  to  the  lens  and  gradually  spreads  out  fan-shaped, 
taking  in  a  section  of  about  30  degrees.  Directly  below  this,  leaving  an  inter- 
vening space  of  about  2  mm.,  another  similar  figure  begins,  but  soon  disappears. 
These  undouljtedly  are  tlie  remains  of  tlie  hyaloid,  which  during  foetal  life  were 
present  on  the  posterior  surface  of  the  lens. 

In  a  monograph  by  Dr.  David  DeBeck,!^  all  the  literature  on  this  sub- 
ject was  compiled,  and  in  his  classification  he  speaks  of  (I)  strands  attached 
to  the  lens  alone;  (J)  posterior  capsidar  cataracts:  (K)  striae  on  the 
posterior  lens  capsule. 

CHAPTER  III. 

MALFOinrATTOXS  OF  THE  LEN8  IX  CONSEQrENCE  OF  UX- 
SY:\lMK'riU('AL  DEVELOPMEXT  OF  THE  ZOXULA  ZIXII. 
COLOBO^F.V  LEXTI8.  (Aril).  One  of  the  causes  of  this  malfoima- 
tion  of  the  lens,  which  is  due  to  an  unsymmetrical  ligament,  is  sought  in 
the  late  closure  of  the  ocidar  fissure,  as  is  at  times  seen  in  cases  of  coloboma 
iridis.  'I'his  is  nearly  always  combined  with  a  slight  malfonnation  of  the 
orbicularis  ciliaris,  in  that  at  the  point  where  the  ocular  fissure  closed  one 
or  more  ciliary  processes  are  wanting  and  the  ciliary  body  is  sim])ly  indi- 
cated.   In  consequence,  tlic  zonula,  if  present  at  all,  is  less  tense,  though  iu 


nZur  Aetiologie  der  Cataracta  Polaris  Posterior.    Dissert  Munchen.  1878. 
18  "Persistent  remains  of  the  F()(>tal  Hyaloid  Artery."    Cincinnati.  1800. 


'47 

all  pr()l)i)l)ili;.v  it  is  wantiii-  ;il  lliis  |.<.inl.  .\>  a  loiill  of  tlii>  ivductioii  of 
tension,  on  (i|)tlialiii<)<(o|iic  cxaininat  ion  tlif  line  of  this  dcrcct  is  marked 
by  a  black  line,  ihc  lens  ai)|)car>  notclicd  al  it>  cd.uc.  iiiid  tlu'iv  i<  an  indent- 
in(?  of  till'  contour  as  a  result  of  inc  ii'a>cd  rctlcxioii. 

IlcyP  develoix'd  llir  in-viiioii>  liieorv.  thai  llii-  iiial  formal  ion  is  due 
to  a  lack  of  nutrition.  <\uv  to  a  dcl'ccl  in  the  anlci-ioi'  1. randies  of  the  hya- 
loid.    This  surely  can  not   have  much   in  it>  favoi'. 

'{'readier  Collins  i:ives  (luile  a  diirerent  e\|ilanatiou  foi-  the  occur- 
rence of  this  malformatiiU).  a>  ha>  already  been  fully  explained  .m  ])ages 
2U  ami   :  I. 

Accoi'din,^-  to  the  latest  woi'k  on  thi>  Mihjecl  hy  Di'.  K.  I'.ock.-  con- 
oenital  malformations  of  the  lens  hclon.i:-  to  the  rarest  of  ocular  findings. 
The  author  reports  six  cases  of  his  own  ami  forty->ix  other  cases  occurring 
in  thirty-eight:  person^  reported   in  literal  ui'e. 

At  the  nu'cting  of  the  Amei'ican  ( )pthalmological  S(.dety.  is'.ll.  Dr. 
C.  F.  Clark.  Columhus.  Ohio,  reported  a  case  of  hinocular  colohoma  leiitis 
in  which  the  accommodative  powei'  was  i-eiained. 

THE  OKXESJS  OK  COl.Ol'.OMA  LKNTIS.  I'.adi  seek>  the  cause 
in  a  delayed  closure  of  the  ociilai-  li>sure.  The  pi'ocess  of  mesodermal  tissue 
which  extends  as  a  process  against  the  v(](ye  of  the  lens,  acts  as  a  mechanical 
obstruction  at  the  respective  point.  .\s  a  result  of  this  ])ressure  along  the 
foetal  fissure,  the  lens  sul)stance  deteriorates,  is  altered  in  its  constitution, 
and  may  simply  assume  a  cloudy  as]>ect:  or  the  more  actively  affected  ]ior- 
tion  may  disintegrate  and  he  absorbed,  aiul  along  this  liiu'  one  will  observe 
a  vacant  siiace  or  fissnre. 

Bach  accei)ts  this  explanation,  but  goe>  still  further,  stating  that  the 
fundamental  cause  is  to  be  sought  in  an  ahiiormally  developed  lens,  which 
in  early  foetal  life  o])poses  the  advancing  mesoblast.  which  in  its  turn 
presses  against  the  gi-adually  enlarging  lens,  or  vice  versa.  Further,  if  the 
adhesions  between  the  vascular  capsule  of  the  lens  and  the  mesoblast  do 
not  dissolve  along  the  entire  equatorial  region,  this  must  lead  to  a  transient 
tension  at  the  respective  ])oint  where  this  attachment  persists,  which  in  its 
turn  leads  to  a  disintegration,  evi'utually  to  a  desti-uction  of  lens  >ubstance. 
The  capsule  may  even  he  pushed  aside  from  the  region  of  stu-h  a  lenticular 
defect,  or  the  defect  may  he  covered  by  this  membrane.  Sim-(>  the  forma- 
tion of  the  caiisule  of  the  lens  is  now  proven  to  be  the  ]iroduct  of  the  cap- 
sular cells,  and  since  nucleated  lens  fibres  must  still  be  ]M'esent  in  the  neigh- 


1  Coloboma  Lentls.   Report  of  Fiftli  luteiiiational  Optli.  Congress,  1877.  p.  16. 
Annal  (VOculist.  1877.  p.  LMlf.. 

2  IMe  Anti-elH.r.'ncn   ("ololx.nie  des   .\ui:upfels   Wieii.  IS'.i:^,. 


148 

borhood  of  the  suiic  lu'iu-c  one  iiuiy  roadily  ^mdcrstand  liow  the  capsule 
may  subse<inciit]y  t'oi'in  a«iaiii.  I'.ach  concludes,  "T  assume  purely  mechan- 
ical causes  for  tlie  prodiiclioii  of  colohdina  of  the  lens,  and  am  of  the  belief 
that,  primarily  we  are  nol  dcalin.i:-  with  a  defect.  Cohdioma  of  the  lens  is 
not  the  resnlt  of  a  forinalive  eri'oi-  in  the  lens  proper,  hut  due  to  an  (tUered, 
(lelerioniled  Jniticular  iikiss.  which  suhsequently  oradually  disa])pears."" 

KCrOPIA  LlvX'riS.  Closely  allied  to  the  two  al)ovo-deserihed  ab- 
normalities is  the  well-known  anoiiui/ie  in  llic  foniuil ion  of  the  ri/e,  known 
as  ectopia  lentis.  It  can  not  he  looked  u])on  as  an  anomalie  of  the  lens, 
unless  there  is  juvsent  ai  the  same  lime  a  change  in  the  form  of  the  lens. 
which  is  seldom  the  case.  The  only  kn.own  difference  seems  to  he  that  the 
lens  is  snudler  or  thicker  than  normal.  Nothing,  however,  goes  to  prove 
that  the  architecture  or  the  arrangement  of  the  fibres  deviates  from  the 
normal.  It  must  therefore  be  assumed,  notwithstanding  the  unequal  length 
of  the  zonula  fibres,  that  the  pressure  exerted  on  the  lens  is  everywhere 
equal.  And  the  fact,  that  the  lenses  which  have  been  ectopionated.  do  not 
especially  often  become  cataractous.  seems  to  indicate,  that  the  nutrition 
of  the  lens  during  life  i>  normal.  Xothing  special  is  known  concerning 
the  cause  of  the  unequal  length  of  the  zonular  fibres.  Here,  once  umre, 
attention  is  drawn  to  Treacher  ('ollins'  explanation,  i)age  '\\.  Since  the 
displacement  in  both  eyes  is  almost  invarial)ly  synnnetrically  upward; 
either  directly  upward,  or  nj)ward  and  to  one  side,  it  does  not  seem  difficult 
to  assume,  that  here  likewise,  closure  of  the  ocular  fissure  plays  an  im- 
portant role. 

Attention  is  first  directed  to  this  condition  from  the  fact,  that  the 
patient  sees  very  poorly,  and  that  vision  can  not  be  improved  with  glasses. 
Vision  can  only  be  improved  by  the  use  of  strong  concave  glasses.  A  prac- 
ticed eye  at  once  perceives  that  the  anterior  cluunher  is  of  uniMpial  depth,  in 
that  one  portion  of  the  iris  is  situated  more  anteriorly  than  the  diher.  The 
uiore  deeply  seated  portion  trend)les  on  moving  the  eye.  On  opt  halnioscopic 
examination,  one  will  see  at  once,  or  possibly  only  aftei'  dilating  the  pu|iil.the 
edge  of  tlie  lens  passing  through  the  pupil,  as  the  segment  df  a  black  ring 
along  the  liiu'  wliei'e  the  iris  li(\s  dee])est.  If  the  attempt  is  now  made  to 
get  a  \iew  (d'  tlie  fundus,  this  can  be  accomplished  in  a  two-fold  manner. 
if  one  looks  tlirctugh  tlu'  lens,  using  the  corrccli(Ui  f(ii-  a  myopic  eye.  one 
nhtains  a.  view  of  the  ])apilla.  and  on  looking  to  the  side  of  the  lens,  using 
the  a])hakic  correction,  one  gets  another  \ie\\  of  the  papilla,  ff  we  now 
inake  tests  for  vision,  the  presence  of  this  condition  can  he  ]iroven  f(n-  dis- 
tance, by  concave  glasses,  where  the  patient  looks  through  the  crystalline 
lens:  the  same  result,  howevei-.  may  he  ohtained  hy  using  catai-act  glasses, 
the  j)atieiif  looking  to  the  side  of  the  leu>.      If  hy  the  one  method  or  the 


149 
other  the  ;in(iiii;ilic  of  rctVacI  ion  is  iiciit  i-;ili/,('il,  llic  >crT)n(l  ]io.i>il)ilit y  will 
iiitert'ci'c  1)111  lilllc.  Ilowcvci-.  witlKMil  ;i  ciiiivcl  imi  ;i  tnic  iiioiioeiilai' 
diplopia  will  (k-cui'.  This  (■(•iidiiioii  can  nt)t  always  Ix-  niadr  apparrnl  to 
the  paticnt^  at  ouvv.  It  (Icjx'IhI.-  upon  the  distance  at  wliicli  tlit;  li^dil  is 
i\'iii()\c(l  I'nini  tlic  patient,  wlidlicr  hotli  iniaiic^  will  liccdinc  ap|>arcnt  Of 
wlit'tlici-  one  will  l)('  suppressed.  IF  one  liad  pi'exionsly  delerniiiied  botii 
(•(inditi.in>  of  refraction,  one  can  easily  lind  llie  distance  at  wliii-h  botli 
iiuayes  iiinst.  become  appai'ent.  .\t  this  |)oint.  as  a  rule,  the  patient  will 
see  both  images  at  once.  The  inia;.:e  which  is  foi'uu'il  without  the  aid  of 
the  crystalline  lens  i>  projected  correctly,  whereas  the  crystalline  lens  acts 
as  a  pi'isni.  Hence  the  iiua^x'  which  passes  tbrou(,di  the  crystalline  lens 
is  projected  falsely  and  in  exactly  the  op[)osile  direction  to  that  in  which 
the  lens  is  Inxated.  'I'his  knowlcd<i-e  can  be  used  in  assistiny-  the  patient 
to  find  the  second  image. 

On  moving  the  eye  or  changing  the  position  of  the  head,  the  lens  may 
also  change  its  position.  'I'be  degree  of  m()I)ility  varies  greatly.  In  extreme 
cases  the  lens  not  only  changes  its  position  in  the  vitreous,  but  it  may  also 
enter  the  anteiior  chand)er.  This  latter  condition  Heyman  has  described 
under  the  title  of  "sixmlaneons  mobility  of  tlie  lens."  (Spontane  freie 
beweglichkeit).  Such  a  condition  must  necessarily  be  preceded  by  an  ex- 
traordinary lengthening  of  the  zonula  libres.  Such  a  condition  has  been 
anatomically  described  by  1).  K.  Muller,  and  thus  placed  beyond  the  reach 
of  hypothesis.  Horner  had  already  drawn  attention  to  the  fact,  that  the 
unequal  development  of  the  zonnla,  as  well  as  a  tendency  to  dissolution 
of  the  sjiinc.  may  be  inln'rited.  This  seems  to  be  attested  by  its  occurrence 
in  both  eyes.  I^duard  Meyer  has  I'eported  an  undoubted  case  of  congenital 
ectopia,  in  which,  in  course  of  yeai's,  the  displact'inent  increased  on  the  one 
eye;  whei-eas.  in  the  other  eye.  the  lens,  without  having  lost  its  mobility, 
when  the  head  was  held  ei-ect,  retui-ned   to  its  normal  position. 

iBe(  U(>r.)  1  :nn  acquainted  witli  a  t'ainily.  in  which  a  brother  and  sister  show 
in  both  eyes  a  syiniiietrical  eetopi.i  lent  is.  Ten  years  ago  both  could  overcome 
the  interference  witli  vision  l)y  cylindiical  glasses.  At  present  this  is  no  longer 
possible.  'I'lie  cliildren  ot  tlie  sister,  a  boy  and  a  girl,  both  are  astygniatic,  and 
Avere  eorreeted  tour  yeai-s  ngo  by  cylinders.  .Vt  tliat  time.  I  measured  the  cornea 
with  the  oi)thalnionietei-.  and  could  not  discover  any  asynietry.  On  dilating  the 
pupils  of  botli  children  oih'  could  see  downward  and  inward  a  dark  spot  at  the 
edge  of  the  lens,  which  1  i)ronouneed  a  congenital  partial  cataract.  Now  the 
c.vlindrical  glasses  are  no  longer  of  use.  and  the  trouble  is  continually  becoming 
more  pronounced,  as  a  luxation  of  the  lens,  rndoubtedly  the  zonula  first  began 
to  give  downward  and  inward,  and  is  gradually  lieeonnng  elongated. 

\'on  (iraefc'^  was  the  lii'st   to  accui-atelv  desciibe  a  case  of  ccuicenital 


Arch,  fur  Qpth.,  I,  S.  343. 


I50 

luxation  of  the  lens.  The  pecnliarities  of  vision  in  these  eases  are  hero 
found  accurately  described;  he,  however,  failed  to  state  whether  this  is  a 
congenital  condition  or  not.  He  seemed  to  believe  that  the  cause  is  a 
Huidity  of  the  vitreous,  and  a,  defect  in  the  natural  partition  wall, though, on 
using  the  o])tlialni()scope.  he  could  not  discover  the  slightest  trace  of  a 
flaky  or  membranous  cloudiness  in  the  vitreous,  and  the  fundus  appeared 
perfectly  normal.  In  the  sime  year  (18r)4)  E.  Yaeger  descnbed  a  case, 
which  bore  a  close  resemblance  to  the  one  mentioned  above,  and  he  de- 
scribed it  as  a  case  of  congenital  displacement  of  the  lens  system.  Stell- 
wag  ^  was  tlie  first  to  describe  an  abnormally  small  lens  as  a  congenital 
anomaly,  and  to  use  the  word  "ectopic"  in  the  sense  we  use  it  today.  From 
now  on.  the  reports  of  cases  of  luxation  of  the  lens  began  to  increase;  also 
explanations  as  to  its  cause.  Dixon,  the  Englishman,  as  the  result  of  a  re- 
port of  a  large  number  of  cases,  added  much  to  the  methods  of  diagnosing 
congenital  luxation  of  tlu'  lens.  Hippel  ^  finally  took  the  last  step,  when 
he  said  that  '"sponfdiieoiis  Iii.niiiun"  and  "ectopia  hntis^'  are  two  entirely 
different  conditions,  in  that  the  former  is  due  to  diseased  conditions  in  the 
eye,  whereas  -the  latter  is  a  malformation. 

CHAPTER  IV. 

ACQUIRED  AXOMALIES  IX  THE  POSITIOX  OE  THE  LENS.  XOT 
DUE  TO  MALE()1«LVT10X8. 

LUXATIO  LEXTIS— LUXATIOX  OF  THE  LEXS. 

Anatomically  considered,  the  accpiired  anomalies  of  position  of  the 
lens,  can  not  in  any  sense  be  considered  as  malformations.  Xevertheless, 
owing  to  the  great  similarity  of  the  symptoms,  both  subjective  and  ob- 
jective, they  will  be  considered  at  this  point. 

The  tei-m  ''lu.valio  lenlis''  embraces  not  only  the  cases  of  spontaneous 
displacement  of  the  lens,  originally  in  their  normal  position,  but  those 
cases  which  occur  in  consequence  of  violence  which  causes  the  lens  to  par- 
tially or  totally  leave  the  fossa  patellai'is.  l^lodigo  suggested  that  we  use 
the  tei-m  ''(Jislocalii).''  instead  of  "luxalio  lentis."  and  this  nauie  might  with 
givat.  |ti'opriety  be  used  in  cases  of  secondary  luxation. 

SPOXTAXEOUS  Ll'XA^JTOX  OF  ^JTIE  LEXS.  EUXATIO  LEX- 
TIS SPOX^WXE.    DEPLACE^rEXT  SPOX^JWXE.    We  are  indebted  to 


4  Wiener  Med.  Woclicuhlatt.  1S.->(i. 

5  "Die  si)oiitiiii('  Inx.itidu  dcr  liiise  >unl   ilire  .•inucltoreiie  ectopie."    .Marburg. 


151 

SiclK'P  for  the  first  accurate  descriptions  of  sponiaiiL-ou.^  displacement  of 
the  lens.  This  can  only  occur  when  the  zonula  zinii  has  been  partially  or 
totally  destroyed.  IF  such  a  defect  in  the  zonula  takes  place  to  the  side  of, 
or  below  the  lens,  a  chancre  in  the  position  of  the  lens  does  not  necessarily 
follow  at  once.  Tvuv.  ..wino-  to  the  specific  weio^hi  cf  the  lcii>.  on  niovins? 
the  eyes,  even  after  they  have  aoain  come  to  rest,  tlu'  lens  will  continue  to 
make  movements.  In  e(.ii^e(|uence  of  these  oseilatiii-r  movements,  the  lens 
may  become  turned  on  its  axis,  so  that  its  one  edge  may  come  nearer  to  the 
cornea  than  the  other:  but  a  real  displacement  to  the  one  side  or  down- 
ward will  not  oeeiir  as  long  as  the  portion  of  the  zonula  zinii  above,  remains 
intact.  As  soon  as  this  becomes  affected  the  weight  of  the  lens  will  begin 
to  exert  its  influence,  and  as  a  result,  the  lens  will  begin  to  sink  downward. 
Xo  matter  where  the  zonula  has  l)eeii  afl'eeted.  owing  to  the  oscillation  of 
the  lens,  in  eourse  of  time  the  zonula  will  give  above,  and  the  lens  will 
becMime  displaced  downward.  It  will  then  depend  upon  the  conditions 
of  the  latteral  portions  of  the  zonula  whether  this  sinking  will  take  place 
exactly  downward,  or  downward  aiul  inward,  or  downward  and  outward. 
This  is  a  very  important  fact,  since  a  lens  can  iu'\er  l)e  .ywntaneoush/  lux- 
ated exactly  upward. 

The  cause  of  this  spontaneous  displacement  lies  either  in  the  condition 
of  the  vitreous  and  the  zonula,  or  in  the  lens  system  itself. 

The  disease  which  is  considered  to  be  most  frequently  followed  by  a 
spontaneous  luxation  is  a  general  fluidity  of  the  vitreous.  (Sijnchysis 
corporis  vitrei.  Aside  from  the  fact  that  the  clinical  picture  of  this  disease 
is  by  no  mean>  a  definite  one.  it  is  impossible  for  the  lens  to  sink  down 
without  the  zonula  zinii  suffering  in  its  continuity.  Although  up  to  the 
present  time  it  has  never  been  quite  clear  in  wlwit  nuinner  a  fluidity  of  the 
vitreous  could  affect  the  zonula,  especially  since  there  is  no  rediution  in 
volume  of  the  vitreous  when  it  is  in  a  fluid  state,  we  are  entitled  to  make  the 
assum])tion:  since,  as  we  have  seen,  the  zonula  is  of  mesoderniic  origin,  as 
is  also  the  vitreous:  hence  the  same  causes  which  lead  to  fluidity  of  the 
vitreous,  may  at  the  same  time  dissolve  the  zonula  fibres.  Hence,  in  cases 
of  spontaneous  luxation,  we  are  not  dealing  with  a  tearing,  but  with  a 
dissohiiion  of  the  zonuta.  However,  when  we  say  this,  we  are  only  saying 
that  the  same  cause,  of  which  we  are  as  yet  ignorant,  causes  a  like  change 
in  both  vitreous  and  zonula. 

A  spontaneous  luxation  nuiy  as  well  lake  place  when  the  lens  is  per- 
fectly transparent,  as  when  it  is  cataractous.  Further  along,  a  different 
factor  will  be  shown  to  be  at  work  in  influencing  the  spontaneous  luxation 


1  Oppenheiru's  Zeitsehrift,  XXX,  3  Heft. 


152 

of  a  cataractous  Jens,  which  factor  has  nothing  to  do  with  the  above-men- 
tioned manner  of  occurrence,  since  in  these  latter  cases  there  is  no  fiuidit} 
of  the  vitreous. 

The  symptoms  of  spontaneous  luxation  necessarily  vary,  depending 
on  the  fact,  whether  the  U-ns  is  transparent  or  not. 

In  cases  of  transparent  lenses,  tlu'  symptoms  are  very  much  like  those 
of  ectopia  lentis:  tlicy  (lilVcr.  liowcvcr.  from  these,  in  that  the  symptoms 
develop  in  a  proportionately  shorter  time.  'Vvml',  as  a  rule,  this  sinking 
dovt^n  takes  place  slowly,  though  always  more  rapidly  than  in  the  cases 
described  under  congenital  ectopia  lentis. 

In  onh'r  to  make  a  differential  diagnosis,  it  is  of  great  importance  to  be 
able  to  determine,  if  for  a  certain  period  of  life,  vision  has  been  normal.  In 
just  such  cases,  where  fonuerly  vision  was  perfectly  normal,  tlie  ]iatient  will 
become  aware  of  the  change,  vision  is  not  so  sliarp,  and  iu  trying  to  see 
accurately,  objects  seem  to  oscillate.  The  lens  begins  to  move  about  behind 
the  iris,  and  in  consequence  the  iris  begins  to  tremble.  Examination  of 
the  refraction  discloses  the  fact  that  the  far  point  has  come  nearer  to  the 
eye.  If  the  lens  has  sunk  down  so  far  that  a  part  of  the  pupil  is  free,  a 
double  refractive  condition  will  result,  together  with  true  monocular 
diplopia,  as  in  ectopia  lentis.  A  further  striking  symptom  is  now  added, 
since  vision  changes  with  each  change  in  the  position  of  the  head,  for  on 
bending  the  head  forward  the  lens  comes  up  close  to  the  iris,  whereas  on 
bending  the  head  backward,  the  lens  falls  back  into  the  vitreous.  In  the 
first  case  the  already  unequally  deep  chamber  becomes  shallower,  whereas 
in  the  latter  it  becomes  much  deeper.  Where  there  is  a  great  mobility, 
symptoms  of  irritation  on  the  part  of  the  iris  and  choroid  may  develop. 
This  is  preceded  by  a  variety  of  ectopic  phenomena.  The  patient  beconu's 
aware  of  the  presence  of  the  lens  as  a  grey  disc,  or  as  a  similarly  colored 
segment  of  a  circle,  and  at  the  same  time  he  begins  to  see  flashes  of  light 
and  tlauu'  like  figures;  likewise,  irritability  to  light,  tearing,  and  pain  may 
be  added. 

If  the  zonula  zinii  lias  been  entirely  dissolved,  the  slightest  jar  mav 
cause  the  lens  to  fall  into  the  antci'inr  cliauihcr. 

In  coui'se  of  time,  lenticular  and  capsular  cataracts  always  follow  in 
cases  where  there  ha>  taken   place  a   luxatitui  of  the  lens  system. 

'^rhe  >| laneous  luxation  of  the  riila nnhiiis  lens  is  ])rodui-ed  in  an  en- 
tirely dilTerenl  manner.  Tlii>  is  not  true  of  all  cataracts  which  spon- 
taneously leave  (he  |»upillaiy  area,  for  it  is  possible  for  the  vitreous  to  be- 
come 11  u  id  in  case>  of  cataract:  without  taking  into  consideratiiui  those 
cases,  in  wliich  tlu'  displacement   i>  of  Mich  a  slight  degree  that   it   ha>  l)een 


153 

overlooked,  but  neverthek'.<s,  in  (■(.ii>r(|iicn(c  ..f  uliidi  the  lens  has  l)Coome 
cataractoiis. 

It  has  long  been  known,  as  an  rslal)lislie(l  fact,  that  after  a  rnlly-dt-- 
vch.pod  senile  cataract  has  existed  lor  a  Inn--  linif.  llic  cataract  may  spon- 
taneously leave  the  pupillary  area.  Bei'ure  this  can  occur,  it  is  necessary 
that  ii  looseninfr  take  place,  between  the  zonula  zinii  and  the  lens  on  the 
one  liand.  and  hctwcon  llic  i)o>tcrior  and  ilic  concave  vitreous  depression 
on  the  other.  Wenzel.  i'.eer.  and  others  liave  reported  that  not  infre- 
quently, on  niakin-i-  a  (lap  incision,  tlie  lens,  together  witli  its  cap>ule, 
would  i)op  out  of  the  eye  with  considerable  force.  This  can  oidy  l)e  ex- 
plained. l)y  assunnng  that  the  tension  on  the  zonula  zinii,  and  perhaps 
also  the  sudden  change  in  the  position  and  form  which  takes  place  in  the 
lens,  the  nionient  the  aqueous  is  evacuated;  and  also  due  to  the  pressure 
the  vitreous  exerts  anteriorly,  is  sufficient  to  tear  the  lens  from  its  con- 
nt'ctions.  It  must  have  been  these  observations  which  led  to  the  develop- 
ment of  those  methods  which  had  as  their  object  the  removal  of  the  U'ns 
together  with  its  capsule. 

The  anatomical  cause  of  such  a  loosening  of  tlie  lens  from  its  attach- 
ments is  not  to  be  sought  in  a  fluid  vitreous.  Xot  only  are  we  in  possession 
of  reports  of  cases  in  which  the  removal  of  the  lens  in  its  capsule  was  not 
followed  by  an  evacuation  of  vitreous,  operators  know  only  too  well,  that 
a  fluid  vitreous  has  a  tendency  to  get  in  front  of  the  lens  and  cause  the 
lens  to  fall  backward  into  the  vitreous.  However,  one  must  not  lose  sight 
of  those  senile  changes  in  the  zonula  fibres  already  described,  which  makes 
them  stifl'er  and  more  brittle,  so  that  they  are  less  able  to  resist  a  sudden 
force  acting  on  them.  However,  the  greatest  stress  must  be  laid  on  the 
condition  of  the  anterior  capsule.  If  our  conception  regarding  the  forma- 
tion of  capsular  cataract  is  correct,  the  formative  stage  is  foHowed  by  the 
stage  of  shrinkage,  just  as  we  see  it  in  cicatrical  tissue.  Since  we  know  that 
the  capsular  cataract  does  reach  its  linut.  in  that  it  does  not  grow  in  the 
periphery,  as  it  does  in  thickness  ad  libitum,  it  must  necessarily  finally  be- 
come reduced  in  volume  after  it  has  reached  its  maximum  growth.  Further, 
since  it  is  formed  on  the  concave  side  of  the  anterior  capsule  on  shrinking, 
it  has  the  tendency  of  becoming  tense  like  the  string  on  a  bow.  and  hence 
exerts  a  certain  amcmnt  of  tension  on  \hv  capsule.  .\s  a  i-esuit  of  tlvs 
tension,  capsular  cataracts  of  long  standing  appear  folded.  Ji.  .Muller,  1. 
c,  pp.  281  and  284).  This  has  been  looked  upon  as  one  of  the  causes  of 
pyramidal  cataract.  Such  shrinkage  likewise  becomes  a  very  im]iortanr, 
factor  in  the  production  of  the  various  forms  which  secondary  cataracts 
assume.  The  greater  the  amount  of  lens  substance  al)sorbed,  the  greater 
will  be  the  eft'ect  on  the  -ha])e  of  the  eiitii-e  len>.  in  cases  in  which  the  cap- 


154 

sule  lias  not  l)eeii  injured.  The  development  of  cataracta  frpunila.  natalis 
and  elastica  will  now  he  more  easily  understood,  since  these  are  principally 
{•apsnlar  cataracts. 

The  s])ontaneous  luxation  of  senile  cataract  is  undouhtedly  favored  l)y 
changes  in  the  zonula  fibres,  and  could  with  difficulty  occur  without  the 
intervention  of  some  form  of  accidental  traumatic  cause,  such  as  vomiting, 
convulsions  or  concussion  of  the  entire  body  and  the  eye;  this  is,  however, 
always  preceded  by  the  formation  of  a  capsular  cataract.  The  tension 
which  is  exerted  on  the  anterior  capsule  during  the  process  of  shrinkage 
must  all  the  more  assist  in  severing  this  connection  between  the  anterior 
capsule  and  the  fibres  of  the  zonula  zinii,  because  this  shrinking  capsular 
cataract  extends  just  to  the  peripheric  endings  where  the  zonula  fibres  are 
inserted  into  the  anterior  capsule. 

This  view  is  strengthened  by  the  fact,  that  in  cases  of  spontaneous  lux- 
ation of  senile  cataract,  as  a  rule,  one  finds  extensive  capsular  cataract; 
further,  that  not  only  in  spontaneously  luxated  lenses,  but  also  in  cases 
where  at  the  extraction,  the  lens  in  its  ca])sule  escapes  by  itself,  one  can 
never  discover  any  remains  of  zonular  fil^res  on  the  capsule.  This  also 
shows  that  the  connection  is  severed  at  the  capsule  and  not  along  the  length 
of  the  zonular  fibres. 

a.  LTJXATIO   LENTIS   TKAHMATICA— TRAVMATIC   LUXATTOX. 

Traumas,  which  may  cause  the  lens  to  leave  its  normal  position,  are 
either  contusions  of  the  eyeball  in  which  the  coats  of  the  eyeball  may  or 
may  not  be  opened,  or  the  zonula  is  ruptured  by  the  direct  action  of  a 
foreign  body  which  has  penetrated  the  eyeball.  In  the  latter  case  tho 
foreign  body  may  eitlioi-  remain  within  or  again  leave  the  eyeball.  If  a 
foreign  body  penetrates  the  eyeball  in  such  a  manner  as  to  sever  the  zonula 
zinii  in  only  a  circumscribed  area,  it  goes  without  saying  thgt  besides  the 
zonula,  cornea,  iris,  and  also  the  vitreous  are  always  involved.  If  the  in- 
jury is  caused  by  a  pointed  instrument,  (such  as  a  needle,  the  shoemaker's 
awl,  a  steel  ])en,  or  a  pointed  knife-blade),  this  will  again  leave  the  eye 
and  the  injury  may  heal  in  a  few  days  without  any  special  reaction.  Fre- 
quently the  case  comes  under  observation  only  after  the  wound  has  healed. 
The  statements  of  the  patient  then  lead  us  to  make  a  very  careful  examina- 
tion. Here  we  find  a  cicatrix  in  the  cornea,  a  hole  in  the  iris,  through 
which,  when  properly  examined,  light  can  be  reflected  from  \hv  fundus. 
If  the  hole  in  the  iris  is  larger  and  extends  perpendicularly  to  the  radiating 
striations  of  the  iris,  the  pupil  at  this  point  will  not  be  so  wide,  and  conse- 
quently not  perfectly  circular.  Tossibly  one  can  detect  a  numluT  of  flakes 
ill  the  vitreous.     .\sj(le  from  (list  urhaiices  of  vision  due  to  opacities  in  the 


■55 
vitreous,  iiiaeciiracy  of  vision  may  develop  as  the  ri'suli  of  a>ly<:iiiali.-iii. 
At  the  ])oint  wliere  llie  Zonula  has  lieeii  -evered.  it  will  e\erl  less  prcssur-^ 
on  the  lens.  At  this  puini  the  len>  l.e((Mnes  thicker,  aiul  in  this  meridian, 
the  eve  will  heeouie  myopic.  Attempts  at  cylindrical  c(,iTeclion  are  as  a 
rule  attended  with  Itnt  >li-hl  >ueeess.  .ince  the  entire  meridian  does  not 
alter  its  relVaclioii.  the  .ippixition  end  of  tlu'  respective  meridian  remain- 
ing fastened  in  its  noiuial  cdndiliou.  The  ivsuh  n\'  >uch  an  injury,  there- 
fore, is  a  ])ei'manent  reduction  of  vision.  .\s  to  whether  or  not  an  iri>  pro- 
hipse  follows  the  injuiw  depends  entirely  on  tlie  size  of  the  corneal  wouml. 
If  this  occurs,  undei-  cei'tain  comlitions  this  must  he  exercised.  It  may 
necessitate  an  iridectomie. 

If,  aside  from  the  above-mentioned  tissues,  the  lens  and  corpus  ciliars 
are  injured,  the  process  of  healing  hecomes  proportionately  nujre  compli- 
cated, and  the  sequehie  for  sight — in  fact,  for  the  whole  eye;  indeed,  the 
second  eye,  since  this  may  he  sympathetically  alTected — nuiy  he  of  the 
very  worst  kind.  Hence  injuries  of  these  parts  are  of  the  very  greatest 
importance,  and  mention  is  made  of  this  here  so  tluU  it  need  not  be  referred 
to  again. 

Though  it  clearly  is  not  within  the  province  of  this  work  to  enter  into 
the  sul)ject  of  SY:\IPATHETIC  OPTHAmilA,  still  it  seems  but 
proper  to  state  that  most  authorities  today  aekm)wledge  that  this 
disease  is  clearly  an  infection.  Where  a  foreign  body,  as  indicated 
above,  penetrates  the  eyeball  and  is  retained,  be  this  a  minute 
spicule  of  iron,  steel,  lead,  copper,  glass  oi-  stone,  it  may  re- 
main free  in  the  vitreous  or  stick  fast  in  the  [)osterior  wall  of  the 
eye;  and,  if  asce])tic.  it  may  become  encapsulated  and  remain  latent  for 
years.  However,  it  nuiy  be  here  stated  that  even  these  capsules  lead  to 
tension  on  the  vitreous  and  eventually  to  loss  of  the  eye,  notwithstanding 
the  isolated  cases  reported  in  literature  in  which  this  result  did  not  follow. 
Leher,2  as  the  result  of  eleven  years  of  experimental  investigation  with 
every  conceivable  substam-e,  studying  its  action  on  the  interior  of  the  eye, 
states,  that  all  the  metals,  even  gold  and  silver,  glass,  etc..  are  gradually 
acted  on  by  the  fluid  media  of  the  eye.  minute  quantities  gradually  dis- 
solved off,  and  thus  act  as  an  irritant  causing  a  purulent  inflammation 
wliich  may  be  dsrcplir  in  its  nature.  The  recognition  of  asceptic  pus  chem- 
ically i)roduct'd,  he  regards  as  of  the  greatest  therapeutic  value.  lUit  where 
micro-organisms  are  carried  into  the  eye  with  the  foreign  body  the  condi- 
tions are  different  and  the  occurrence  of  sympathetic  opthalmia  becomes  a 


2  Die  Enstehun^  der  Kntzundunjr  nrul   die  -wirkmri:   iter   I'nTziniduiiirs  ere- 
gende  Schadlichkeiteu.    Leijjsi;:-.  IWtl. 


156 

possibility,  if  not  a  i»n>l)aljility.  Weckcv  coiiddcrcd  tin?  subject  of  such 
great  inipoi'tancc  that  he  .levotcd  an  entire  chapter  to  its  discussion.^  He 
critically  analyzed  some  twenty-two  cases,  and  finally  concluded  that  the 
tension  of  cicatrical  bands  on  the  ciliary  body  led  to  chronic  irritation  and 
sympathetic  opthalniia.  Many  of  these  earlier  experiences,  read  in  the 
light  of  our  present  imderstanding  of  the  subject,  are  clearly  an  infection. 
"On  New  Year  eve,  1870.  a  piece  of  a  percussion  cap  flew  into  tbe  eye  of  a 
twelve-year-old  boy  in  the  neighboring  county  of  K.  I  (Beclier)  found,  down- 
ward and  inward  from  the  edge  of  the  cornea,  two  millimeters  distant  from  its 
transparent  edge,  a  wound  about  three  millimeters  long,  into  which  the  iris 
had  prolapsed.  After  excising  the  prolapse,  a  coloboma  was  found  extending 
to  the  perii)hery.  After  the  Avound  was  healed,  on  looking  through  this  colo- 
boma. one  could  see  a  distinct  indentation  of  the  edge  of  the  lens.  Colobortw 
Laitix  Artificink',  and  this  also  caused  astygmatism.  This  piece  of  percussion 
cap  became  encapsulated  without  in.iury  to  tlie  eye.  and  after  a  lapse  of  five 
years  the  eye  still  performs  its  function." 

If.  aside  from  cornea,  iris,  zonula  and  vitreous,  fhc  Iciis  and  cUiari/  bochi 
are  involved,  the  prognosis  and  the  duration  of  the  trouble  will  materiallv 
depend  on  the  extent  of  the  injury  to  the  parts.  It  then  would  certainly 
be  advisable  to  cut  short  a  long  and  painful  stage  of  healing  and  forestall 
a  possible  sympathetic  affection  of  the  other  eye  by  an  immediate  enuclea- 
tion. 

A  contusion  of  the  eyeball  is  frequently  followed,  without  the  coats  of 
the  eyeball  being  ruptured  at  any  point,  by  a  stretching  and  final  separa- 
tion of  the  fibres  of  the  zonula  zinii,  and  as  a  consequence,  exerting  a  tem- 
porary or  pernument  influence,  on  the  form  and  position  of  the  lens. 

It  is  questionable,  and  has  not  as  yet  been  proven,  whether  or  not 
the  individual  fibres  of  the  zonula  possess  the  property  of  elongation  or 
distension.  It  is  stated  that  where  the  anterioi-  chamber  is  evacuated,  the 
anterior  capsule  of  the  lens  comes  in  contact  with  the  cornea,  and  that  this 
could  not  possibly  occur  without  the  elongation  of  the  zonula  fibres.  It  is 
only  certain  that  the  zonula  fibres  do  not  tear,  otherwise  the  lens  could 
not  retain  its  normal  position  with  a  complete  retention  of  its  normal 
functions.  Instead  of  an  elongation  of  the  zonula  fibres,  such  a  consider- 
able moving  forward  of  the  lens  (about  -2:]  mm.)  could  be  caused  by  an  an- 
tei'ioi'  movement  of  ibie  ciliary  body,  togethei-  with  tbe  ii'is.  and  the  in- 
creased convi'xily  of  the  anlerioi-  sui-face  of  tbe  lens. 

"It  would  not  h.-ivc  been  n(M-essjiry  (o  luenlion  tliis  elongation  of  tlic  zonular 
fibres,  if  it  were  not  for  a  case  reimrted  by  Aub.4  whicli  he  tried  to  explain  by 


3  Pathologie  and  Tlieraiiie  des  I>insensystems,  p. 

4  Arch.  f.  A.  und  ()..  II.  I.  p.  !.••">'.». 


'57 
usiu;;-  this  liyiioihcsis:  A  in:in.  ."..'.  yr.-irs  of  nuc  w  liilr  uiii  liuiiiiiiv^  w.-is  siruck 
oil  tlu'  (\v('lt;ill  by  :i  slioi  fnnii  ;i  sIkiIlmiii.  A  single  slioi  \v:is  inudvcil  from  iho 
oiitcr  iiortioii  of  tlic  (•oii.jiiiictiv.-i  tlic  next  <l.iy.  On  tlic  fourth  (l:iy  iiftci-  the  op.T- 
iilioii  :i  pi-oiiouiiccd  (•ii-cuiiicoiiic;il  iiijcclioii  wms  in-fsml.  Tln'  coi'iir.-i  \v;is  flfjir. 
tilt'  ;mi('iioi-  cli.-iiiilicr  .-ihoul  oiic-li.ilt  lillcd  with  bloody  scnim.  |iu|)il  iiiin-ow.  aud 
iris  clinnjrcd  in  colur.  At  the  uppn-  ;ind  oiitci'  h;iir.  tin-  iris.  r(pi;il  to  atMHit  oiif- 
slxth  of  its  circumfei'onct'.  was  prominfiii.  Attn-  ilic  use  of  atropine  tlic  lens 
was  disclosed   nnin.jnrcd.    lint    imslicd    ror\\ar<l    in    its   \ippcr   and   otiicr   portion. 

On  the  si'vcnth  day   tin-  inMamnialory   condition  sec d  to  siiWsiilc.    '{"lie   pnjnl 

was,  dilated  ad  inaxiniiini.  liiit  aliovc  and  outward  ilie  lens  still  .ontinucd  to 
jn-ess  the  iris  Idrward.  A  sii(  k  iicld  diagonally  Iteforc  tlu'  eye  ai)peared  thicker 
at  its  upper  aud  outer  end  than  at  its  lower  autl  inner.  Turned  '.)(»  dev;reos  the 
stick  appeared  everywhere  of  equal  thickness.  By  the  use  of  a  concave  cylinder 
1-20.  placed  in  the  eorrespondiiii;  axis,  vision  was  inii)roved  to  20-100.  On  the 
thirteenth  day  the  i)romiuence  of  the  iris  and  the  nu'tarnorphosie  had  disap- 
peared. Owing  to  a  slight  degree  of  myojiia,  \'.  equal  to  20-30,  and  the  cylinder 
no  lon.uer  improved  vision.  Anb  declares  that  this  condition  of  the  lens  was 
caused  by  a  partial  relaxation  of  llie  zonula:  but  he  fails  to  state  in  what  man- 
ner he  ima.iiincs  this  to  have  occurred.  Aril''  translates  'relaxation'  by  the 
word  distension  lor  elasticit.vl.  and  without  the  slightest  hesitanc.v  accepts  this 
as  a  condition.  But  returning  to  Aub's  case  I  wish  to  draw  attention  to  the 
fact  tliat  he  has  not  i>roven  that  the  zonula  is  elastic,  and  further,  that  a  partial 
]>aralysis  of  tlie  ciliary  muscle,  at  the  point  where  tlie  shot  struck  the  eye.  would 
explain  all  tlie  iihenomeiia   which  he  reports." 

TJ^AIMATIC  LUXATION  is  always  the  result  of  a  tearing  of  the 
zonula  zinii  without  an  injury  of  the  lens  capsule.  Since  it  can  not  be  as- 
sumed that  tears  in  the  zonttla  can  heal,  we  are  justified  in  making  a  diag- 
nosis of  a  partial  tear  of  the  zonula,  in  all  cases  in  which,  in  conseqtience 
of  a  eontusi(jn.  the  [ilienomena  of  a  dislocation  of  the  lens  system  appear 
and  do  not  retrogress.  In  the  beginning,  these  phenomena  are  the  devel- 
opment of  a  myopia  and  the  gradtial  shortening  of  the  distance  of  the  far 
point  of  the  eye.  If  the  tension  which  the  zonula  e.\erts  on  the  crystalline 
lens  is  abolished,  owing  to  an  extensive  or  jiossihle  total  tear,  the  equa- 
torial diameter  will  be  diminished  and  the  axial  diameter  will  be  increased. 
Owing  to  this  change  in  the  form  of  the  h'lis.  the  far  ])oint  will  approach 
closer  to  the  eye.  lUit  where  there  is  a  total,  or  even  a  very  extensive  tear- 
ing of  the  zonula,  accommodation  beconu^s  imi)ossible.  and  there  will  be 
but  one  point,  which  will  neither  coincide  with  the  former  far  or  near 
point,  at  which  it  will  be  possible  to  see  distinctly.  The  former  symptom 
will,  however,  only  then  become  Aaluable  for  differential  diagnosis,  where 

5  L'ber  die  Verletzimgen  des  Auges  in  (Jerichtsarztlicher  Zeziehung.    Wiener 
Med.  Wochenschrift.  1.S74,  No.  15.  S.  200. 


158 

we  know,  what  the  refraction  of  the  eye  was  previous  to  the  accident.  In 
manv  cases,  liowever.  by  conipai'ing  tlie  eye  with  tlie  uninjured  one,  we 
can,  with  a  considerable  dej^rcc  of  certainty,  form  an  estimate.  (It  must, 
however,  not  be  forgotten  that  not  infrequently  the  refractive  conditions 
of  the  two  eyes  are  not  alike;  hence  it  can  never  give  more  than  an  ap- 
proximate resnlt.) 

If  the  lens  is  not  held  equally  tense  in  all  directions  by  the  zonula 
fibres  and  lield  fast  in  its  connection  with  the  ciliary  processes,  on  moving 
the  eye,  the  lens  will  begin  to  make  independent  movements,  in  which 
the  iris  will  participate.  (Trembling  of  the  iris — iridodnnesis).  However, 
this  symptom  alone  does  not  decide  anything  as  long  as  the  lens  is  trans- 
parent. For  the  iris  may  independently  make  such  movements  if  the 
pupillary  margin  is  free  and  an  abnormal  amount  of  aqueous  is  behind  it. 
In  exceptional  cases,  this  can  be  observed:  as,  per  example,  where  there  is 
a  large  cornea  and  a  relatively  small  lens,  in  cases  of  myopia  with  relatively 
deep  anterior  chamber,  in  eases  of  buphthalmus,  and  in  cases  of  synchisis 
corporis  vitrei,  where  the  lens  lies  deeper  than  the  normal. 

b.  SUBLUXATION  OF  THE  LEXS. 

In  cases  in  which  there  is  a  partial  tearing  of  the  zonida,  the  lens  may 
retain  its  position  unchanged  in  the  concare  hollow  of  the  vitreous  for  an 
indefinite  length  of  time.  In  most  cases,  liowever,  after  a  time  the  lens  in 
a  two-fold  manner  changes  its  position,  in  that  it  not  only  turns  on  its 
equatorial  diameter,  but  also  moves  toward  the  side  where  the  zonula  is 
still  intact.  Due  to  this  oblique  position  or  turning  of  the  lens,  the  iris  is 
pressed  forward  at  one  point,  and  consequently  the  anterior  chamber  at 
that  point  is  shallower.  The  opposite  edge  of  the  lens  approaches  the  axis, 
and  on  using  the  opthalmoscope  it  may  be  seen  when  the  pupil  is  small, 
and  must  appear  when  the  pupil  is  dilated  as  a  black  segment  of  a  circle. 
However  small  this  segment  of  a  circle  may  be,  by  means  of  this,  we  can 
definitely  determine  the  position  of  the  lens  and  the  kind  of  transposition 
we  have  before  us.  'I'Ir'  edge  may  even  become  visible  to  the  patient,  as  a 
black  ring.  If  the  edge  of  the  lens  passes  tlii-ougii  a  impil  of  normal  size, 
naturally,  everything  will  be  seen  double. 

The  iinportaucc  of  a  subluxation  ri'sts  on  the  fact,  that  uiuler  all 
circumstances  thcj-e  will  be  ])ermanent  interference  with  vision.  Aside 
from  this,  experience  has  taught  us.  that  in. nearly  all  cases,  if  the  patient 
lives  long  enough,  a  total  luxation  will  finally  result.  Further,  in  course 
of  time  the  lens  will  always  become  cataractous.  This  frequently  happens 
before  the  zonula   is  completely   torn.     The  latter  must   naturally  follow, 


Ihitin.u-  of  the   Ici 

1>.     (Ml     Mlii\ 

•ill-   tl 

end  to  ail  ahiioriii; 

111  tension 

(111    tile 

V  iiiav  (iiialU    lca( 

1   1(1  cvcliti 

^.    cll.-l 

159 

'ad 

ai 

id     the 

lin 

iii.-i- 

zonula 

i>  ; 

ind 

syiiip- 

lih 

res 

as  the 

-!"■ 

ik  of  n 

since  the  constant  o 
eyes,  necessarily  niiis 
fibres.  The  same  ca 
tonis  of  glaucoma. 

As  has  already  been  stated,  a  rcsiitnti( 
result  of  liealing  is  not  to  he  expected.  li( 
therapie  tor  subluxation.  In  some  special  eases  ilie  attempt  may  he  made 
to  give  aid,  by  the  use  of  glasses.  (Mtlier  by  looking  through  the  dislocated 
lens,  or  to  the  side  of  it.  II'  the  lens  has  become  catanictous,  the  attempt  may 
be  made  to  give  assistanci'  by  an  irideetomie  or  by  an  extraction. 

The  mechanism  by  means  of  which  a  tearing  of  the  zonula  is  brought 
about,  is  as  little  understood,  as  is  the  mechanism  oi  all  other  internal  in- 
juries of  the  eye,  which  result  from  a  conhisio  hulbi.  Jt  appears  most  prob- 
able, that  the  globe,  owing  to  its  peculiar  situation  in  the  orbit,  can  only 
be  struck  in  its  anterior  position,  by  a,  blunt  force,  and  most  frequently 
is  flattened  in  a  direction  from  in  front,  below  and  outward.  l>ackward, 
upward  and  inward.  Such  a  flattening,  owing  to  the  inconipressibility  of 
the  media  of  the  eye  and  the  relatively  slight  elasticity  of  its  coats,  can  not 
occur  unless  the  globe  is  distended  in  the  eqautorial  region.  If  the  cornea 
is  the  part  compressed  the  distension  will  take  place  at  the  sclero-corneal 
ring.  By  this  means  we  can  most  easily  explain,  why  it  is  that  choroidal 
ruptures  occur  most  frequently  in  the  equatorial  region  and  very  nearly 
concentric  and  opposite  the  place  to  which  the  force  was  applied.  This 
also  explains  the  relatively  frequent  occurrence  of  iridodialysis  and  tears 
of  the  zonula.  Relative  to  the  latter,  we  must  also  consider  that  in  every 
case  of  concussion  of  the  eyeball,  the  lens,  owing  to  its  greater  specific 
weight,  tries  to  make  more  extensive  movements  and  hence  pulls  on  the 
zonula,  which  tears  when  a  certain  degree  of  tension  is  brought  to  bear 
on  it.*^ 

The  lens  may  retain  its  position  in  the  fossa  jiatellaris  in  cases  in 
which  there  is  a  partial,  as  well  as  when  there  is  a  total  tearing  of  the 
zonula.  In  most  cases  instantly,  in  other  cases  after  a  certain  length  of  time, 
the  lens  changes  its  ])osition,  remaining  in  contact  with  the  patellar  fossa 
or  leaving  it  altogether.  Thv  first  condition  occurs  most  ri-e(piently  and 
will  continue  longer  wlu-re  the  zonula  is  hut  partially  torn.  This  may  be 
designated  as  a  suh-lti.nilioii.  (Arit).  in  contradistinction  to  a  liLniliaii.  in 
which  the  crystalline  body  has  entirely  h'ft  the  hollow  grove  of  the  vitre- 
ous, and  is  found  t'ither  in  the  anterior  chamber  or  wedged   in  tlie  ])upii 


6  Yoral.  Arlt.    Wiener  INIed.  Woclienschrlft.  1874,  No.  12.  p.  2.''.1. 


i6o 

or  in  tlie  vitreous,  oi-.  liimlly.  iliai  it  lia>  Ix-eii  (li'a^-pod  entirely  out  of  the 

evel)all. 

Tlu^  force  wliifl)  eause.s  a  ronliisia  hull  I,  as  a  rule  strikes  the  eve  in  a 
direct  manner.  Tlie  body  eoming  in  contact  with  the  eye  may  1)e  rela- 
tively lartje  as  com])ared  with  the  size  of  the  eye.  and  have  considerable 
thickness,  or  have  a  blunted  end  on  a  rounded  ])i'oininence:  and  this,  aside 
from  causino-  ;i  o-eneral  tlatteninii'  of  the  ulobe.  may  cause  a  locally  deeper 
impression  without  peneti'atinii'  the  coats  of  the  eyeball.  I)Ut  il  is  nor 
necessary  that  the  foi-ce  >ti'ike  the  eye  in  a  direct  manner.  Thrusts,  blows, 
gunshot  wounds  which  >tiikt'  the  neighborinp;  bones,  may  likewise  cause  a 
concnssion  of  the  eyeball.  Fimilly.  it  may  be  mentioned  that  projectiles 
flying  ])ast,  close  to  the  eye,  may  cause  a  roimnotio  h>ilhi.  During  the  war 
of  "lt)-71.  1  (Becker)  saw  two  cases  of  injury  of  the  eye  wh.ich  were  caused 
in  this  manner.  True,  both  cases  were  ruptures  of  the  choroid,  not  teaj-s 
of  the  zontda.  but  since  the  former  did  occur,  it  can  not  be  doubted  that  the 
latter  is  a  piossibility. 

e.   TOTAL  LUXATIOX  OF  THE  LENS. 

Everything  which  has  been  said  regarding  the  manner  in  which  sub- 
luxation may  be  caused,  is  also  true  in  this  instance.  A  trauma  of  greater 
intensity,  instead  of  causing  a  subluxation,  causes  a  luxation.  .\s  a  rule, 
a  total  luxation  is  preceded  by  the  entire  tearing  of  the  zonu.la  ziidi:  how- 
ever, one  can  understand,  that  a  few  fibres  may  remain  intact,  though  the 
lens  l)e  entirely  removed  from  the  fossa  patellaris. 

On  which  factor,  the  direction  of  the  luxation  of  the  lens  (U'])en(ls,  is 
not  known:  the  symjitoms  naturally  vary  and  dept'nd  entirely  on  the  posi- 
tion of  the  lens.  117/f/;  llie  Inxatal  lens  is  found  in  llir  anfcrinr  chnnihrr.  as 
the  direct  result  of  a  trauma,  we  see  a  round  body,  with  an  ahnost  golden 
colored  ring  which  lies  concentric  to  the  l)ase  of  the  cornea,  and  it  has  a 
very  (lece|ttive  similarity  to  a  di'op  of  oil.  Thi>  body  does  not  entirt'ly  fill 
the  anterior  chandx'i'.  but  the  ii'is  is  not  visible,  sim-e  it  has  been  inverted. 
Aside  from  this  phenomenon  of  total  refit'ctiou  of  the  edge  of  the  lens,  one 
can  see,  on  focal  ilbnuination.  in  the  ti-aiisparenl  body,  radiating  >n'iations 
and  splits,  which  can  be  traced  to  the  lens.  If  such  an  eye  is  examined 
shoi'tly  after  the  injni-y.  one  sees  the  results  of  the  action  of  the  direct 
trauma,  in  the  neighborhood  of  the  eye.  whereas  the  eye  itself  is  free  from 
any  ii-rilation.  Lalei-.  howcvei-.  (in  most  ea,-es.  aftei'  a  few  (hiys).  ciliary 
injection  and  even  swelling  of  the  conjunctiva  bull)i  sei>  in.  and  the  globe 
becomes  glancomatose  and  exceedingly  ])ainfid.  Then  ihe  cornea  becomes 
«lond\   at   the  point   whei-e  the  lens  is  in  contact    with   il.  and   linally.  as  the 


i6i 

subjective   sympldin 

a.nl 

infill  ra 

lion    t;()    on    inci-easing.    per 

foration    take> 

place.     The  liinil   re- 

nil    i.- 

;,  escape 

■  of  1  he  lens  and    pnrnleni    | 

.hlhisis  of  the 

glol)e. 

The    lens   docs 

not,   : 

d\\ay>    ( 

■oniplctely    enlei-     ihc     anlei 

rior    chamber, 

o\viii,i;'  to  I  lie  spaslic 

conn 

•aclion  ( 

if  the  sphincler  iridis.  I'oi-  ji 

list  as  the  lens 

is  ]»;issiii,u'   t  liroiiuli   1 

1...    ,, 

mpil.   il 

nia\'    become    lixcd.       llere 

the   picture  is 

highly  cliai-actci'isiic 

and 

can  not 

be  mistaken.      Nearly  alwa; 

^s  do  we  see  a 

more  or  less   transp; 

u'cnt 

,    ronml 

and    tlatteniMl    body    exteiK 

ling  ol)li(iuely 

into  the  anterior  chamber,  ami  at  its  edge  can  be  seen  the  \vell-k]U)\vn  shin- 
ing, reflected  ring.  In  most  cases,  such  a  condition  is  transitory.  If  the 
spasm  coidiiuies.  pain  will  be  added  to  the  iiitert'erence  witli  vision.  The 
patient  seeks  relief,  which  can  be  given  him  by  the  energetic  use  ol:' 
atropine.  If  this  is  not  done,  glaucoma  will  follow,  and  finally,  as  the 
result  of  ulceration,  the  eye  will  becouu'  phthisical.  It  appears,  that  ex- 
ceptionally this  condition  uuiy  be  tolerated  for  a  considerable  length  of 
time.  13ader'  describes  an  eye,  which  is  in  the  museum  at  Moor- 
fielcTs  Hospital,  London,  .showing  a  lens  in  its  ca])sule.  tixed  in  the  pupil, 
and  which  had  takeu  on  ])ermanently  a  biscuit  form,  lie  fails,  however, 
to  state  whether  the  lens  attained  this  position  as  the  direct  result  of  a 
traunui.  or  whether  this  was  simi)ly  the  result  of  a  change  of  position  of  a 
freely  nu)vable  lens,  M'hich  had  become  wedged  in  the  ]ni]nllary  area. 

The  lens  is  most  frequently  luxated  into  the  vitreous.  Since  it  has  a 
heavier  specific  weight,  hence  after  a  tinu'.  if  not  at  once,  we  may  seek  il 
in  the  lower  portion  of  the  vitreous  space.  It  will  now  depend  largely  on 
the  condition— that  is,  the  consistence — of  the  viti'eous.  and  most  probably 
also,  whether  or  not  a  portion  of  the  zonula  fibres  have  remained  uninjured, 
if  the  lens,  on  nu)ving  the  eyes,  will  remain  ([uiet,  relatively  s])eaking,  or  if 
it  make  very  wide  excursions.  We  must  also  renunnber,  that,  owing 
to  these  active  movements  of  the  lens,  the  vitreous  must  gradually  become 
diseased;  that  is,  fluid.  The  lens,  enclosed  in  its  capsule,  may  remain 
transparent  for  a  long  time;  it  will,  lunvevei'.  finally  become  cataractous. 
Though  the  capsule  ]»reveuts  the  lens  from  being  absorbed,  it  will  neverthe- 
less, gradually  beconu'  smaller.  It  is  not  known  whether  the  intracapsular 
cells  will  undergo  a  hyperplasia  where  a  normal  lens  sinks  into  the  vitre- 
ous, as  the  result  of  a  trauma.  TiUxated  lenses  examined  showed  incipient 
capsular  cataracts.  However,  it  could  not  be  determined  whether  this  was 
the  result  of.  or  had  existed  previous  to,  the  luxation.  This  is  mentioned 
simply  to  draw  the  attention  of  my  colleagues  to  this  question,  owing  to 
its  great  importance. 

7  The  natural  and  morbid  chanfros  of  the  human  eye.   etc.    London,  1868, 
p.  260. 


I  62 

,1.  K1M-:K1.V  .McnKAl'.LK  I.KXSES. 
I'lulci-  this  name,  a  condition  lias  been  described  and  illustrated  by 
innumerable  ease  re])orts.  whieh  may  result  just,  as  well  from  congenital 
ectopia  lentis,  as  in  conse([uence  of  -pontaneous  or  traumatic  luxation.  This 
name  was  introduced  by  TTeyman.  The  cases  belonging  to  this  category 
date  back  a  very  long  tinu'.  The  common  symptom  of  all  these  cases  is, 
that  the  lens,  no  matter  what  the  position  of  the  head  or  eye,  always  takes 
a  position  relative  to  its  weight.  This  does  not  only  refer  to  a  change  of 
])osition  in  the  vitreous.  I»ut  the  lens  may  also  become  wedged  in  the  pupil- 
lary area,  oi*  evi'U  get  into  the  ai";terior  chaml)er. 

In  cases  of  congenital  ectopia  we  must  assume  that  the  zonula  fibres 
have  an  abnormal  length.  As  a  result,  the  lens  may  slijt  into  the  anterior 
chamber  or  fall  back  again  into  the  vitreous.  ""Such  a  case,  I  (Becker) 
saw  at  Arlt's  clinic,  where  a  boy.  eight  years  of  age.  could  easily  accom- 
plish this  change.  Since,  when  this  small  lens  was  in  the  anterior  chamber, 
fine  indentations  were  observed  all  around  the  periphery  of  the  lens,  which 
undoubtedly  were  due  to  the  tightened,  tense  zonula  fibres:  hence  this  case 
served  to  reiiioxe  any  doubts  in  my  mind,  that  there  are  cases  of  freely 
movable  lenses  in  which  the  zonula  is  not  lorn." 

The  symptoms  which  such  a  freely  movable  lens  cause,  are  in  part 
piirely  optical  in  their  natui-e:  in  ])art  pathological,  since  they  cause  pain, 
and  other  sul)jective  syni]»toms  which  give  rise  to  the  necessity  for  opera- 
tive interference  if  we  desire  to  prevent  total  destruction  of  the  eye. 

Arlt  reported  a  case.s  illustrating  the  first  mentioned  symptom.  A  carpenter, 
48  years  of  age,  who  had  always  been  in  perfect  health,  and  wlio  durins;  his 
school  days  had  had  good  vision,  gradually  later  on  became  nearsighted.  In  his 
45th  year  he  suddenly  developed  monocular  diplopia  in  both  eyes.  At  the  end 
of  one  year  the  double  sight  disappeared  again.  If  lie  lay  on  liis  back  he 
imagined  that  he  saw  in  front  of  each  eye  a  round  <lisc.  almost  like  a  drop  of 
oil.  liaving  a  dark  edge.  For  a  time,  for  distance  he  used  convex  glasses;  he. how- 
ever, liad  to  discontinue  their  use.  (ienerally.  however,  he  could  read  ordinary 
printed  reading  mailer  without  spectacles;  only,  liowever.  when  lie  held  it  close 
to  his  breast.  In  directing  the  eyes  downward  lie  caused  tlie  lenses  to  apply 
themselves  closely  b(>iiiiid  tlie  iris,  in  tlie  i)Ui)illary  area,  and  llius  he  was  en- 
abled to  road. 

'I'lic  following  case  is  reported  by  .Noyes.i'  A  man  4.''>  years  of  age  was  struck 
ill  tlic  left  i'\v  \\y  tlic  list  of  .-inother.  Three  weeks  later  the  diiigiictsis  of  lux- 
Mtioii  (lowiiw.-ird  into  ihe  vitreous  w:is  lu.-ide.  His  ref ruction  was  that  of 
aphakia.    A  wee]<  later  tlie  ii.-itieiit  reiH.rted  tli:il  he  saw  good  .-igjiiii.    Tlie  crystal- 


Die 

Kr: 

lllklieiteli 

.les    \iige> 

c.  III.  p.  .-..  ls.-,(; 

.\ll( 

•]i.  r 

iir  .\ngeii 

1111(1   Olire 

11.    ileilkun.le.    I 

'63 
liut>  U>us,  as  coultl  oasil.v  he  (Icicriniiicd  liy  llic  coiidilioii  of  Die  iris,  wliich  was 
pressed  I)ack\var(l,  and  by  liif  li.ylil  cdjic  of  tiic  Iciis.  liad  sliiyjird  iiito  tlic  an- 
tfi-ioi- cliandtcr.  It  was  still  in  its  capsnlc.  and  iiad  a  I'ainl  aniltcr  colm-,  l)ut  at)- 
.solutely  transitarenl.  roiicspondinu  1(.  the  :\iXi-  of  ilir  patient.  'Piie  eiiaiijj:e  of 
position  was  l>rou.i;lit  :il»ont  l>y  tiie  patient  snee/in.i;  violently  after  takin>r  a 
piuoli  of  sntiff  ou  leavin.t;-  the  clinic,  where  his  pni)il  had  been  widely  dilated 
by  atropine.  Innnedlately  thereafter  lie  noticed  that  vision  was  imi)roved.  Ex- 
amiuation  of  his  refraction  disclosed  II ni.  (Mjual  to  I-IS;  \'.  equal  to  20-40  on  his 
rijiht  eye:  liis  left  in.iur(>d  eye  M.  equal  to  1-0.  As.  ni.  :24.  \.  20-50.  The  myopia 
is  explained  by  the  advance  of  the  nodal  point,  also  as  a  result  of  the  increase 
convexity  of  the  lens,  wliich  had  been  loosened  from  the  zonula  attachment. 
Noyes  states  tliat  tin-  astysmatism  is  due  to  the  fact  that  since  the  lens  does 
not  completely  till  out  the  anterior  chamber,  it  sinks  down;  hence,  its  axis  and 
that  of  the  cornea  do  not  coincide,  btit  that  of  the  lens  lies  somewhat  deeper. 
There  are.  however,  most  certainly  other  factors  at  work  which  cause  the  lens 
to  suffer  in  its  symmetrical  form. 

Tlie  presence  of  the  lens  in  the  anterior  chamber  may  Ix;  l)orn  for  a 
long  time  without  destruxing  tlio  eye;  in  fact,  for  yeai's.  Jl  is  hardlv  pos- 
sible foi-  the  condition  to  exist  without  disturbing  the  functions  of  the 
eye.  The  pathological  changes  which  follow  affect  the  cornea,  which  be- 
comes cloudy  when  the  lens  comes  in  contact  with  it;  tlie  iris  becomes 
hyperacmic  and  loses  its  color,  and  cyclitis  is  developed.  \Vith()ut  the  de- 
velopment of  an  exudate — that  is.  tlie  development  of  true  iritis,  a  severe 
ciliary  injection  develops,  and  to  this  chemosis  may  be  added.  At  the  same 
time,  the  glol>e  becomes  tense  and  hard,  and  the  other  symptoms  of  sec- 
ondary glaucoma  develop.  In  some  cases,  in  a  proportionately  short  space 
of  time,  the  globe  changes  its  f(u-m,  the  area  of  the  sclerosis  close  to  the 
cornea  becomes  bluish  in  color,  and  a  staj)hyloina  intercalare  develops. 
The  globe  l)t'comes  i)ear-slia])ed  and  the  axis  of  the  globe  may  become  enor- 
mously t'longated.  The  inHammatni'y  symptoms  increase  and  finally  either 
lead  to  ulceration  of  the  cornea,  with  loss  of  the  lens,  so  that  phlMsis  lulhi 
results,  or  the  inflammatory  syinpioins  gradually  subside,  leaving  an 
amaurotic  t'ctatic  globe,  which  gives  rise  to  no  furtlier  trouble.  In  such  a 
case  one  will  find  the  lens  considerably  diminished  in  size,  adherent  to  the 
coriu^a. 

It  appears,  that  in  cases  in  which  tlie  zonula  is  intact,  the  permanent 
presence  of  the  lens  in  the  aiHerior  chamhei-  (free  niol)ilily  of  the  lens, 
owing  to  congenital  lengthening  of  the  /oniila)  will  niiieh  sooner  lead  to 
intense  symjitoms  of  reaction,  than  in  cases  in  which  the  lens  is  perfectly 
free  from  its  suspensory  ligaments.  It  is  most  probable,  that  the  great 
danger  of  a  partial  luxation,  is  due  to  the  constant  tension  which  the  re- 
maining ])()rtiou  of  the  zonula  exerts  on   the  ciliary  body  (Von   Graefe). 


1 64 

Heuce  the  lens,  which  is  luxated  into  the  anterior  chamber,  may  involve 
the  cornea  and  iris,  o\vin<>-  to  direct  contact,  and  the  ciliary  body  as  the 
result  of  tension  of  the  zonular  fibres. 

As  long  ago  as  ISriO  Arlt  lo  described  such  oases  of  persistent  luxation  of  the 
lens  into  the  anterior  chamber.  The  occurrence  of  growing  together  of  lens 
and  cornea  was  noted  by  von  Graefe  (Arch,  fur  Opthal.,  XV.  3,  158).  and  he 
states  that  such  cases  are  the  result  of  dislocation  of  the  lens  in  the  early  years 
of  life.  Such  lenses  can  be  successfully  extracted.  As  regards  vision,  we  can 
only  expect  good  results  before  staphyloma  intercalare  has  developed.  I  (Becker) 
have  been  given  the  accurate  history  of  a  case  and  the  operative  result,  through 
the  kindness  of  Prof.  Mauthner.  The  nine-year-old  N.  .\.  is  said  to  have  seen 
well  lip  to  her  eighth  year.  From  this  time  on  her  vision  began  to  diminish, 
said  to  have  resulted  from  a  fever.  In  the  left  eye  the  iris,  in  its  upper  half, 
is  more  anteriorly  situated  than  in  its  lower  half.  The  pupil  is  black,  and 
somewhat  displaced  upwards,  irido-donesis.  The  refractive  media  are  clear. 
The  eye  is  highly  myopic,  irregularly  astygmatic.  but  shows  no  staphyloma. 
With — y^  vision  can  be  improved  to  Ag.  On  use  of  atropine,  full  dilation  of  the 
pupil  is  obtained,  but  the  lower  margin  of  the  lens  can  not  be  seen.  The  right 
eye  shows  a  normal  conjunctiva  and  cornea;  no  ciliary  injection.  Near  the  high- 
est point  of  the  anterior  chamber  is  located  the  greyish  white  and  cloudy  lens. 
It  is  closely  adherent  to  the  posterior  surface  of  the  cornea,  and  is  immovable. 
It  is  smaller  in  all  its  diameters,  and  is  shrunken  to  about  two-thirds  its  normal 
size.  The  iris,  as  far  as  can  be  judged,  shows  no  abnormality.  The  pupil,  which 
can  not  be  dilated  by  use  of  atropine,  is  completely  covered  by  the  lens.  On 
May  23,  1870,  Mauthner  extracted  the  lens  of  the  right  eye  by  means  of  a  peri- 
pheric linear  incision.  The  Graefe  knife  passed  through  the  Aequator  Lentis, 
and  the  part'  of  the  iris  which  was  pressed  forward  was  excised.  The  lens, 
which  oil,  pressure  did  not  come  out,  was  finally  removed  with  a  Yaeger's  cir- 
cular spoon.  Nevertheless,  a  portion  of  the  lens  remained  adherent  to  the  pos- 
terior wall  of  the  cornea.  A  portion  of  this  was  removed  with  a  Daviel's  spoon, 
without,  however,  causing  the  cornea  to  give  up  its  non-transparent  and  cloudy 
appearance.  No  special  reaction  followed  the  operation.  At  the  end  of  five  days 
a  severe  episcleral  injection  developed;  on  the  seventh  new  vessels  became  vis- 
ible, extending  from  the  line  of  the  corneal  incision  up  to  the  part  where  the 
cloudiness  existed  in  the  posterior  portion  of  the  cornea.  The  lower  half  of  the 
pupillary  margin  is  adherent  to  the  cloudy  corneal  tissue.  In  about  one  week  the 
episcleral  injection  and  new  formed  vessels  disappeared.  By  means  of  a  broad 
iridectomie  doAvnward,  made  on  the  22d  of  June,  vision  was  increased  to  fg 
by  use  of  -|-l-4.  equal  to  -|-10  D. 

The  pathological  and  anatomical  conditions  of  the  case  may  be  explained 
by  the  examination  of  an  eye,  which.  I  am  sorry  to  say.  was  sent  to  me  (Becker) 
without  a  history  by  Dr.  Schmidt,  of  Odessa.     It  is  exceedingly  pear-shaped, 

10  Die  Krankheiten  des  Auges,  II,  274. 


'65 
lias  a  deep  cxca vatidii  (if  llic  ()i)tir'  nerve,  aiul  sliows  a  (letai-liiiieiit  of  tlie  vitre- 
ous, ciliai-y  stapliyloiiia.  and  in  its  anlerioi-  cliainlx'f.  almost  at  liie  anterioi-  pole, 
is  a  lens  .•'.'o  mm.  in  tliickness.  and  4'-..  mm.  in  widtii.  Tlie  lens  is  ench.sed  in  its 
capsule.  wiii<-li  is  slu'nni<en  at  some  jioints;  it  is  eataiaetons.  and  adln'i-enl  to 
tlie  postefior  stu'faee  of  tlie  cornea.  Hxamiiied  with  ilie  naked  eye.  tiie  lens 
appears  held  adherent  to  the  cornea  by  a  mass  of  exudate.  The  microscopical 
e.xannnatictn  of  the  halt"  of  the  eye  placed  at  my  disposal  was  made  by  my 
assistant.  Dr.  Raab.  'Phis  siiowed  that  at  the  point  ot'  attachment,  the  corneal 
cloudiness  extended  almost  to  Bowman's  nieuibrane.  and  that  this  wa.s  perme- 
ated by  blood  vessels.  At  which  point  these  vessels  stand  in  connection  with 
the  vessels  of  the  cornea,  can  not  be  decided  from  this  half  of  the  eye.  The 
deseemetis  had  been  severed  over  a  wide  extent  of  surface,  had  drawn  back 
and  was  folded  upon  it.self  ui)ward.  and  downward  it  had  rolled  itself  up  spirally 
in  a  most  characteristic  manner.  A  new  formation  has  pushed  its  way  in  be- 
tween the  deseemetis  and  the  original  corneal  tissue,  which  also  extends  in 
various  directions  and  to  a  varying  extent  over  the  outer  surface  of  the  shrunken 
capsule.  The  lens  has  no  connection  with  the  iris,  which  passes  transversely 
across  the  anterior  chamber  from  its  place  of  origin  at  the  corneal  edge  (5V1>  mm. 
behind  the  pole  of  the  cornea).  The  cornea  is  thicker  in  the  center  than  at  its 
periphery.  The  Corpufi  CU'utre  is  exceedingly  atrophic,  the  ciliary  processes  ap- 
pearing as  thin  ridges.  .V  most  exact  description  of  the  case,  together  with  the 
illustrations,  can  be  found  in  the  second  edition  of  Becker's  Atlas  (Die 
Pathologische  Topographie  des  Auges),  Plate  XYIII.  This  case  differs  from 
Mauthner's.  in  that  in  the  former  a  ciliary  staplyoma  had  not  as  yet  developed, 
and  consequently  one  could  expect  an  improvement  in-  vision. 

The  phenomena  which  were  observed  during  and  after  the  operation  at  the 
line  of  attachment,  especially  the  persistence  of  the  cloudiness  at  the  point  and 
the  development  of  vessels  and  their  disappearance  again,  are  fully  explained 
by  the  foregoing  examination.  Where  violent  symptoms  of  reaction  begin  to 
develop,  both  in  cases  of  spontaneous  luxation,  as  well  as  traumatic  luxations 
in  the  anterior  chamber,  a  threatened  ulceration  of  the  cornea,  ending  in 
l)hthisis.  and  a  total  loss  of  vision,  dtie  to  secondary  glaucoma,  can  only  be 
averted  by  an  early  extraction.  Hence.  Arlt  advised  the  use  of  a  small  Beer's 
knife,  and  in  e.icli  case  he  decides  according  to  the  special  features  of  the  case, 
whether  or  not  the  capsule  should  be  opened  at  the  same  time.  If  we  desire  to 
excise  the  iris  after  the  lens  has  been  extracted,  this  can  be  grasped  by  a  hook. 
It  will  scarcely  be  possible  to  avoid  escape  of  vitreous.  In  order  to  avoid  a 
possible  ihoroidal  hemorrhage,  it  is  advisable  to  first  induce  deep  narcosis.  If 
the  operation  is  made  before  the  development  of  glaucoma,  the  result  will  be 
better.  The  peculiar  features  which  may  develop  during  the  process  of  healing, 
where  glaucoma  has  already  set  in,  are  Illustrated  by  the  following  case: 

The  seventy-three-year-old  wife  of  a  gardener,  while  chopping  wood,  struck 
herself  in  the  right  eye.  In  the  beginning  the  pain  was  not  severe;  she  could 
see,  "only  different."  as  she  expressed  it.     On  the  third  day  the  pain  became 


i66 

very  violent,  and  vision  was  almost  totally  abolished.  On  being  called,  I  found 
the  lens  in  the  anterior  chamber,  the  iris  pushed  bade  and  the  entire  eyeball 
red  and  hard.  She  could  still  count  fingers.  On  the  eleventh  day  I  made  the 
extraction  upward  by  means  of  a  flap  incision.  The  lens  escaped  easily  without 
loss  of  vitreous,  and  the  iris  was  not  excised.  Pain  ceased  at  once,  the  wound 
healed  very  quickly,  and  the  patient  was  ready  to  be  discharged  on  the  tenth 
day.  Since  she  could  not  receive  proper  attention  at  home  she  remained  at 
the-  clinic.  I  made  a  trip,  and  to  my  astonishment  on  my  return,  after  an  ab- 
sence of  three  weeks,  found  her  still  at  the  clinic.  Owing  to  increased  intra- 
ocular tension,  the  wound  which  had  healed  so  quickly  commenced  to  give,  and 
"Without  a  perforation  having  ever  taken  place,  or  the  iris  cicatrized  in  the 
wound,  I  found  an  ectatic  condition  of  the  cicatrix.  Notwithstanding  the  most 
intense  pain  the  patient  would  not  permit  me  to  enucleate.  Therefore,  I  made 
an  incision  through  the  cicatrix,  and  permitted  sufficient  vitreous  to  escape,  so 
that  phthisis  bulbi  followed. 

If,  at  the  time  of  the  trauma  the  kixated  lens  is  already  cataractous, 
the  diagnosis  is  easy.  Owing  to  its  cloudiness,  no  matter  where  located,  the 
lens  can  be  found.  The  subjective  symptoms  are  subject  to  change,  inso- 
much, that  the  lost  vision  may  be  restored.  Eespecting  the  aetiology,  one 
must  only  be  reminded  of  cases  of  long  standing  cataract,  where,  owing  to 
the  shrinkage  of  new  formations  on  the  inner  surface  of  the  anterior  cap- 
sule, the  connection  between  the  capsule  and  the  zonula  are  loosened,  and 
in  these  cases  a  contusion  of  the  eyeball,  or  a  concussion  of  the  entire  body 
may  be  the  exciting  cause  to  bring  about  the  condition.  Here  the  luxa- 
tion is  really  not  spontaneous,  but  one  must  assume  that  if  the  accidental 
cause  had  not  taken  place,  the  same  result  would  nevertheless  have  occurred 
in  course  of  time.  The  operative  procedure  of  reclination  must  also  be 
looked  upon  as  a  cause  of  luxation.  The  occurrence  of  luxation  into  the 
anterior  chamber  dviring  the  operation  of  reclination  became  a  matter  of 
great  importance  in  the  history  of  opthalmology.  Even  in  extraction,  luxa- 
tion of  the  cataract  plays  a  prominent  part. 

A  fi-eely  movable  cataractous  lens  is  also  desi'ril)e_d.  especially  the  cal- 
careous cataract.  As  vision,  as  a  rule,  is  totally  lost  in  cases  of  calcareous 
lenses,  it  is  simply  a  question  of  removing  a  calcareous  lens  which  has 
fallen  into  the  anterior  chamber,  or  become  wedged  in  the  pupil,  either  for 
cosmetic  purpose,  since  the  white  or  yellow  amber-colored,  wrinkled  body 
disfigures  the  eye  very  much:  or  one  opcrntod  on  iUHount  of  tlie  pain  or 
inter-current  inflammation.  In  sucli  oixTations  one  must  l)c  prepared,  not 
only  for  the  escape  of  vitreous,  l)ut  lor  large  choroidal  hemorrhages.  For 
this  reason,  the  prognosis  as  tlie  result  of  an  operation  is  exceedingly 
dubious. 

If.  Ml   1lic  lime  of  the  contusion  of  Ihe  ulobe.  the  sclera   is  rnnlurcfl. 


i67 
in  iK'aHy  vwvy  ease  llio  lens  will  he  i-eiiiovcd   from  il>  iioi-mal   prisilion.     It 
ma}'  I'oinaiii  in  the  eye,  and  thus  heeoiiie  a  new   soiiree  of  danger,  for  in 
nearly  every  ease  the  capsule  is  opened.     The  proiiiiosis.  however,  does  not 
entirely  dojiend  on  the  lens:  liciicc  we   need   mil   consider  these  cases  any 
further.     It   is.  howe\er.  nol   an    inrre([neiil    occurrence   I'oi-  the   lens  to  be 
forced  out   of  the  eyi'  at   the  time  of  the  accident.     The  scleiotic  is  nearly 
always  ruptnred.  in  a  directi(ui  which  is  ciuu-enti'ic  to  the  base  of  the  cornea, 
at  about  3  (at  inost.  4)  mm.  distance  from  the   hase  of  the  cornea,  most 
frequently  upward,  aiul  upward  and  inward:  oidy  isolated  eases  have  been 
reported  where  such  a   I'upture  has  taken  place  downward.     Whether  the 
conjunctiva  ru])tures  at  the  time  or  not,  depends  on  the  f(u-ce  of  the  hlow. 
In  the  tirst  case,  the  lens  will  be  found  in  the  conjunctival  sac,  or  it  is 
never  found.    Iris  and  corpus  ciliare,  as  well  as  a  good  portion  of  the  vit- 
reous, prolapse  from  the  wound,  and  the  entire  globe  collapses.     iUood  is 
found  in  the  anterior  chamher  and.  as  can  be  seen  in  cases  which  heal,  the 
vitreous  is  permeated  with  large  clots  of  blood.     Treatment  consists  in  ex- 
cising the  ])rolapsed  uvea  and  vitreous  and  applying  an  asceptic  dressing 
to  the  eye.    The  application  of  cold,  especially  ice  compresses  seem  to  be  of 
great  benefit.    If  the  conjunctiva  has  not  been  ruptured  we  will  find  under 
a  vesicle-like  elevation  of  the  conjunctiva,  the  lens  in  its  capsule,  appear- 
ing like  a  round,  transparent  body,  which  on  focal  illumination  gives  the 
well-known  shining  circle.     In  this  location,  the  lens  may  retain  its  trans- 
parency for  weeks,  so  that  the  rupture  of  the  sclerotic,  through  which  the 
lens  escaped,  may  become  entirely  healed.    It  is  a  striking  fact,  that  in  these 
cases  of  luxation  under  the  conjunctiva,  neither  iris  nor  vitreous  prolapse 
from  the  wound.     The  iris,  however,  is  frequently  inverted  at  this  point, 
and  simulates  a  coloboma.    Where  the  sclerotic  closes  again  before  the  lens 
is  removed,  tlie  process  of  healing  is  a  much  simpler  one.  the  conjunctiva 
acting  as  a  barrier  against  infection. 

SKCONDAKY  LUXATION  OF  THE  LEXS. 
DISLOCATIO  LEXTIS. 

Among  those  pathological  conditions  of  a  com})licated  character, 
Avhich  lead  secondarily  to  a  luxation  of  the  lens,  those  which  lead  to  staphy- 
lomatous  formations  occupy  the  first  position. 

If,  owing  to  the  perforation  of  a  corneal  ulcer,  the  aqueous  escapes,  or 
if  as  the  result  of  a  trauma,  the  anterior  chamber  is  opened,  the  iris  and 
lens  will  apply  themselves  to  the  posterior  surface  of  the  cornea.  If  the 
opening  closes  again,  so  that  no  more  aqueous  escapes,  under  certain  con- 
ditions both  iris  and  lens  will  return  to  their  normal  position.     But  just  as 


1 68 

the  iris,  owing  to  an  antiTior  .synechia,  may  he  held  in  ilie  wound,  tlie  lens 
may  likewise,  with  oi'  witliont  a  previous  opening  of  the  capsule,  be  held 
fast  by  new-formed  cicatrical  tissue  and  thus  he  prevented  from  fullv  re- 
turning to  its  normal  position. 

It  is  well  known  that  cases  of  large  perforating  wounds  of  the  cornea 
lead  to  partial  or  total  corneal  staplyloma.  The  influence  which  this  exerts 
on  the  position  of  the  lens  depends  entirely  on  the  fact  whether  the  entire 
lens  escaped  at  the  corneal  perforation  or  whether  the  capsule  was  simply 
opened,  and  a  portion  of  the  lens  was  evacuated,  or  whether  the  lens,  either 
intact  or  opened,  has  become  cicatrized  to  the  bulging  cornea:  and,  finally, 
where  all  these  conditions  are  not  present,  whether  the  corneal  staplyloma 
does  not  secondarily  lead  to  a  dilation  of  the  annuhis  ciliaris,  and  thus 
cause  a  partial  or  total  teai'ing  of  the  zonula  zinii.  Accordingly,  we  may 
find  in  the  staphyloma  either  no  lens  at  all.  or  a  calaracfa  .■^rriindaria.  or 
the  lens  is  adherent  in  front,  or  it  may  he  perfectly  unchanged  in  its  normal 
])osition,  or  it  may  finally  he  found  floating  in  the  vitreous,  still  attached  to 
the  remains  of  the  zonula.  In  cases  of  buphthalmus.  just  as  in  cases  af 
staphyloma  intercalare,  the  zonula  finally  tears,  and  the  lens  is  luxated. 

If  the  pus,  in  case  of  panopthalmitis,  or  purulent  hyalitis  and  choroid- 
itis, forces  its  way  out  of  the  eye,  in  the  majority  of  cases  it  will  do  so,  so 
close  to  the  perijdiery  of  the  cornea  as  to  partially  distroy  the  zonula.  The 
lens  will  he  displaced  and  inil)e(lded  in  a  puruU'ut  mass,  which  is  partially 
derived  from  tlie  vitreous  and  ciliary  hody.  partially  from  the  iris.  In 
these  cases,  the  lens  assumes  the  most  peculiar  shapes,  which  no  doubt 
result  (being  preceded  by  softening)  from  an  unequal  pressure  exerted  in 
a  purely  mechanical  way.  Finally,  new  formations  which  originate  in  the 
retina  and  choroid,  as  soon  as  they  come  in  contact  with  the  lens,  force  the 
lens  from  its  normal  position,  and  can  cause  it  to  assume  the  most  won- 
derful shajies.  A  liijdrops  raiiicrdc  nnlcrious  will  press  the  lens  backward; 
a  rhdniidHis  srrosd  or  (jhuicoiiKt  will  force  it  forward.  In  a  case  of  spon- 
taneous abscess  of  the  vitreous  which  followed  years  after  an  operation  for 
glaucoma,  I  observed  how  the  lens  M'as  pressed  forward  until  it  touched 
the  posterior  surface  of  the  conu'a,  even  before  a  change  in  the  shape  of  the 
eye  occurred. 


i69 
CHAPTER  V. 

MALFORMATJOXS    OF   TUK    LKXS    W  I'lIIOl'T   DEMOXSTRATA- 

BLE  PuVTHOLOUlCAL  CHANGP^S  IN  THE  OTHER 

PORTIOXS  OF  THE  EYE. 

IXDEXTED  OR  XOTCIIKI)  LKXS.  Owin^-  to  their  great  rarity, 
anomalies  in  form  of  tlie  lens  in  otherwise  healthy  eyes  are  exceedingly 
interesting.  The  case  which  Becker  describes  in  both  his  works  is  evi- 
dently one  and  the  same.  In  his  Anatomy,  he  states  that  it  occurred  in  a 
syphilitic  child  a  few  weeks  old,  whereas  in  his  "Pathology  and  Therapy," 
where  the  case  is  fully  described,  he  says  that  it  occurred  in  a  boy  eight 
years  of  age.  Both  cases  are  referred  to  in  the  same  illustrations.  (See 
Becker's  Tafl.,  XII.,  Fig.  3,  4.  o). 

"I  (Becker)  am  in  possession  of  Imtli  eyes  of  a  boy  8  years  of  age.  wlio  liad 
congenital  syphilis,  and  who  died  in  the  hospital  of  Vienna  in  1866.  The  eyes 
were  sent  to  me  because,  during  life,  the  boy  had  seen  very  poorly,  without  any 
outward  cause  being  discernible.  The  lenses  in  botli  eyes  were  found  to  be 
of  normal  size,  the  anterior  capsule  of  normal  thickness  and  curvature.  On  the 
posterior  surface,  however,  1.25  mm.  from  the  edge,  there  existed  a  horse-shoe 
like  indentation  open  toward  the  bottom.  As  preparations  of  Dr.  Goldzieher 
disclosed,  the  course  of  the  fibres  in  the  interior  of  the  lens  was  an  anomalous 
one,  and  thus  accounted  for  the  external  appearance." 

Knies  ^  believed  that  he  had  seen  a  similar  case,  because  he  observed 
peculiar  shadows  on  making  an  opthalnu)scopic  examination. 

The  anatomical  connection  between  this  anomalie  and  central  cataract, 
spindle  cataract  and  zonular  cataract  will  he  referred  to  further  along, 
when  these  various  forms  come  under  consideration.  A  particularly  in- 
structive case  (i)age  18())  has  been  anatomically  considered  by  Schirmer. 
which  illustrates  the  possibility  of  its  production  in  a  manner  analogous 
to  that  of  a  spindle  cataract.  This  has  likewise  been  referred  to  by  Knies 
(quoted  above). 

LENTICOXUS.   CRYSTALLOKOXUS.   ANTERIOR  ET  POSTERIOR. 

The  entire  literature  on  this  subject  comprises  but  sixteen  cases,  hence 
it  will  be  seen  how  extremely  rare  is  its  occurrence. 

The  first  case  was  described  by  Webster  ^  as  one  of  hnticonus,  and  the 

1  Tiber  den  Spindelstaar  und  die  Accommodation  bei  demselben.  Arch.  f. 
Opth.,  Bd.  XXIII.  1.  p.  219. 

2  Ein  Fall  von  Lenticonus  aus  der  Prexis  der  Dr.  C.  R.  Agnew,  Arch,  fur 
Augen  und  Ohren.    Knapp,  Moos  B.  lY,  1874,  p.  262. 


''j^M^SCVKbin 


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W    '^^     v»S#1j     rTif 


'feai-^wsi  3*«HK- 


:afe.-».  te-  aft- 
«<     ae  •*«»*  a  ^t^t^Mift.  sai&SHr  ;a»eiBftc  aganet.  ■  iiii'iii— fii . 

-._;_-:-  -  ■       ^       -  .'.-:11c 

-       -        ^  *  a 

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■  ■        ^   -  -.    ■  r  Si 


rir^  iC^    :i0^2;;:^2^  :i«jLtniur-u^    \_U;i    -;_!iO  ^St 


172 

large.     This  latter,  however,  is  not  sharply  detined,  and  aside  from  this  are 
numerous  fine  punctate  opacities. 

On  moving  the  eye  the  opacities  undergo  such  a  high  degree  of  parallactic 
transposition  in  the  opposite  direction  that  one  must  secure  very  slight  move- 
ments to  prevent  entire  loss  of  these  opacities  out  of  the  pupillary  area.  These 
movements  are  decidedly  more  marked  than  we  are  accustomed  to  note  them, 
when  there  are  opacities  at  the  posterior  pole  of  the  lens,  and  hence  permit  of 
our  drawing  conclusions  as  to  the  probable  seat  of  these  opacities.  One  can 
safely  say  these  opacities  are  further  back  than  is  the  usual  position  of  the 
posterior  surface  of  the  lens. 

The  Purkinje-Sanson  pictures  are  present.  The  one  belonging  to  the  pos- 
ttrior  surface  of  the  lens  makes  very  rapid  movements  on  changing  the  position 
of  the  lamp. 

On  focal  illumination  we  at  once  see  the  cause  of  the  peculiar  pictures  noted 
above.  One  sees  a  funnel-shaped  Iwdy  deep  in  the  sagittal  axis  of  the  eye.  which 
reflects  the  light.  The  base  of  the  body,  as  far  as  on  can  judge,  is  at  the  pos- 
terior surface  of  the  lens,  and  from  here  it  projects  backward  into  the  vitreous. 
This  funnel-shaped  body  is  perfectly  transparent,  and  is  continuous  with  the 
otherwise  totally  transparent  substance  of  the  lens,  and  its  limiting  surfaces 
show  the  same  spots  observed  with  the  nairrot",  only  where  they  were  dark  they 
now  appear  white,  strongly  reflecting  the  light,  .ttie  one  "first  described  above 
appearing  almost  exactly  at  the  tip  of  the  funnel.  Hence  there  can  be, no  doubt 
as  to  the  diagnosis  of  lenticonus  posterior. 

Opthalmoscopic  examination  in  the  direct  method,  to  the  side  of  the  funnel, 
permits  a  good  examination  of  the  fundus,  which  shows  nothing  abnormal.  In 
the  direct  method  only  the  periphery  of  the  fundus  can  be  examined,  and  shows 
Em.  It  is  impossible  to  gain  a  sharp  image  of  the  papilla;  the  best  can  be 
obtained  by  a  12  D  or  13  D.  The  large  opacity  at  the  tip  of  the  funnel  is  best 
seen  with  a  -|-  28  D. 

That  lenticonus  posterior  is  neither  a  formative  nor  a  developmental  anom- 
alie,  but  rather  a  patliological  process,  seems  to  be  attested  by  the  fact  that 
opacities  were  present  ou  the  posterior  capsule.  One  could  then  compare  this 
condition  to  that  of  keratoconus,  where,  as  a  result  of  softening  and  tliinning 
of  the  capsule,  less  resistance  is  offered  to  the  presence  of  the  growing  lens. 

I'rof.  Knapp^  reported  a  ca^ie  in  ISJll.  He  consider?  the  conus  con- 
genital and  stationary,  and  suuocsted  tlic  tcnii  "ccfasic"  or  ••twravation  of 
the  posterior  pole  of  the  lens.  Since  tlicn.  hut  three  eases  liave  been  re- 
ported, one  by  J.  Mitvalsky,^  one  by  Eisaeh,'  and  one  by  Dr.  Gullstrand.* 


5  Knapp's  Arch..  Vol.  XXII.  p.  28,  1891. 

fi  Eiu  Xener  Fall  von  Lenticonus  Posterior  niit  tlieilweiser  persistence  der 
Arteria  Ilyaloidea.    Centralltlatt  fur  pi-.-ik  Augenlieilkunde.  Mars,  1802. 

7  Eiu  Fall  von  Leiiliconus  Posterior.  Zclieiidcrs  Klin.  Monatshlatt.  March. 
1892. 

8Ein  Fall  von  Lenticonus  I'oslerior.  .Nonlisk  Oi.th.  'IMdskrirt.  V.  1.  Ceutral- 
blatt,  p.  377.  1892. 


173 

In  a  recent  |).i|»i'r  Ity  L.  fJiicli.-'  the  ciitiic  snhjcft  of  lenticoniis  poste- 
rior is  reviewed. 

He  states:  "'I'l)  to  the  [)reseiit  time.  \m\  sixteen  oljservations  of  len- 
ticonns  posterior  have  been  Tiuule,  and  iccently  hut  three  aiiatotnical  ex- 
aminations." 1" 

Clinical  oI)svrvati()ns  (lisciosed  the  I'aet.  that  this  nialforniation  oc- 
curred in  twelve  cases;  eight  times  on  one  eye,  four  times  on  both.  In  the 
eight  cases,  the  other  eye  was  pronounced  normal  seven  times.  In  the  four 
cases,  the  statement  is  made  that  one  case  is,  positively,  and  the  other  three 
cases,  in  all  probability,  congenital. 

]n  eight  cases  a  cataracta  polaris  posterior  is  said  to  have  been  present, 
together  with  the  lentieonus  posterior.  Jn  two  cases,  other  opacities  of  the 
lens  were  present.  Jn  two  easfs.  remains  of  the  hyaloid  artery  were  found, 
and  in  one,  a  rudimentary  persistent  i)upillary  membrane  on  the  other  eye. 

Bach  examined  two  cases  occui-ring  on  two  rabbits,  and,  as  a  result 
of  his  anatomical  examinations,  draws  the  following  conclusions: — 

"A  disturbance  in  the  development  of  the  eye  is  the  cause  of  lentieonus 
posterior.  Sutficient  facts  are  at  hand  to  Justify  us  in  asserting  that  during 
the  development  of  such  eyes,  there  .is  an  anomalous  formation  of  tlie  lens, 
possibly  a  slight  disintegration  at  the  posterior  pole,  together  with  a  per- 
sistence of  the  vascular  capsule  of  the  lens,  which  latter  rema'.ns  in  contact 
with  a  foetal  vitreous  strand.  Then,  as  the  eye  increases  in  size,  this  strand 
exerts  tension  on  the  posterior  capsule,  drawing  it  out.  and  finally  ruptur- 
ing the  sanu>:  at  the  same  time  the  posterior  cortical  substance,  following 
the  direction  of  least  resistance,  diffuses  itself  posteriorly,  and  forms  the 
lentieonus.  Fnrtlier.  tlie  lens  substance  may  swell  up,  and  tl-.us  lead  to 
ruptitre  of  the  ea])su]e.  There  seems  to  be  no  doubt  that  lentieonus 
posterior  is  due  to  tension  exerted  on  the  posterior  capsule  by  the  con- 
nective tissue  strand,  which  runs  through  the  center  of  the  vitrecxis.  Dis- 
turbance in  the  i-etrogressiv(>  ehanges  in  the  hyaloid  artery,  is  cervainly  an 
aetiological  factor  in  the  genesis  of  lentieonus  posterior." 


9  Path.  Auntomische  Studien  uber  Verscliiedenp  Missbiklnnsen  des  Aiiges. 
Graefe  Arcli..  Vol.  XLV.  Part  I.  189S. 

10  Perjieus  Ed.  Huphthalmus  niit  Leuticonus  Posterior.  \vch.  f.  Auponheilk. 
XXXV,  1  Heft,  S.  1;  Hess  C.  Path.  Anat.  Studien.  etc.  (Jraefe  Arcli..  Vol.  XLH. 
Part  III,  p.  214. 


CHAPTER  VI. 

PAKTIAL  CATAKAOTS. 

A. 

AXIAL  CATAEACT.     CATAEACTA  AXIALIS. 

Only  such  cataracts  should  be  considered  as  partial,  which  have  re- 
mained as  such  for  many  years  or  during  the  whole  of  life;  hence  they  are 
also  stationary.  All  partdal  or  stationary  cataracts  which  are  not  the  result 
of  a  trauma,  are  congenital  or  develop  during  the  years  the  lens  is  grow- 
ing (zonular  cataract).  The  forms  of  partial  cataract  which  occur  most 
frequently  are  found  on  a  line  connecting  the  two  poles  of  the  lens.  Hence 
they  are  called  axial  cataracts.  Formerly  they  were  called  cataracta  cen- 
tralis, without  regard  to  the  fact,  whether  they  were  in  the  centre  of  the 
lens,  or  at  its  anterior  or  posterior  pole;  the  centre  of  the  pupil  and  the 
centre  of  the  lens  being  looked  upon  as  identical  points.  But  as  long  ago 
as  1814,  Benedict  ^  drew  attention  to  the  uselessness  of  such  a  nomen- 
clature, and  he  proposed  that  centralis  should  be  applied,  only  to  those 
rare  cases  in  which  an  opacity  of  foetal  origin,  and  confined  to  the  nucleus 
of  the  lens  remained.  Those  opacities  due  to  inflammation  of  the  capsule 
of  the  lens  and  located  at  the  anterior  pole  are  designated  as  cataracta 
capsularis  punctata. 

The  axial  cataracts  are  situated  either  in  the  centre  of  the  lens,  or  at 
its  anterior  or  posterior  pole. 

1.  CATAEACTA  CENTEALIS   (LENTIS). 

congp:nital,  centeal  lens  CATAEACT. 

During  life  the  central  cataract  appears  as  a  siiiall.  white,  globular 
opacity  in  the  nucleus  of  the  lens,  exactly  in  that  place,  where  genetically 
one  would  expect  to  find  the  oldest  fibres.  The  glaring  white  hght  which 
the  central  cataract  reflects  gives  evidence  of  the  intensity  of  the  opacity  at 
that  point. 

Such  central  cataracts  have  repeatedly  been  observed  at  birth,  hence 
they  are  most  certainly  congenital.  There  are,  however,  cases  (as  will  be 
shown  fmilicr  along)  in  wliich  tlie  opacity  of  a  zonulai-  calaract  is  so  in- 
tense as  to  simulate  a  central  cataract. 

Tlie  reniiiinder  of  the  lens  may  l>e  |»ei-i'ectly  trans])arent.  and  vision 
excellent.  From  this  we  may  also  conclude,  that  the  curvature  of  the  an- 
terior and  posterior  capsule  is  normal.     In  such  cases  the  central  cataract 

iMonographie  des  Grauen  Staar's.    Breslau. 


175 

is  often  discovered  by  the  merest  chaiKH':  often  not  until  very  advanced 
life.  More  frequently,  however,  this  form  of  ciitaract  is  complicated  by 
other  forms,  togetlier  witli  inishujiinis.  Ifcnic-  hclicvc^  iliat  ilic  nystagmus 
is  iuit  due  to  tlu'  calaract  alone,  hut  to  M)iHe  di.-ease  of  the  muscles  or 
nt'rve  inervation. 

Tlu'  seat  of  this  form  of  calaract  must  be  situated  where,  according  to 
the  development  of  the  lens,  one  would  expect  to  find  the  oldest  lens  fibres; 
those  which  had  grown  in  a  saggital  direction;  hence,  we  mnst  come  to  the 
conclusion,  that  it  was  the  fate  of  the  lens  fibres  which  belong  to  the  second 
})eriod  of  foetal  development  to  form  tliis  varit-ty  of  cataract.  In  very  tliin 
meridional  sections  of  hunum  Icjises  taken  from  tlie  end  of  foetal  life  and 
the  beginning  of  extra-uterine  life,  one  can  recognize  these  fibres  enclosed 
in  the  concentric  lamellae.  It  is  especially  worthy  of  note  that  in  the 
sheep  during  the  second  period  of  development  there  is  at  times  an  en- 
tirely perverse  position  and  unequal  growth  of  the  proximal  cells.  Though 
we  can  not  conclude  from  this,  that  the  cloudiness  is  the  result  of  the  ab- 
normal position,  nevertheless,  the  observation  has  shown,  that  at  times  the 
abnormal  changes  do  take  place.  If,  however,  one  is  not  inclined  to  believe 
that  subsequently  there  is  cloudiness  of  this  conglomeration  of  cells,  one 
can  conceive  of  a  condition  here,  as  it  occurs  in  lamellar«'cataract,  where, 
over  a  mass  of  lens  cells  which  have  become  cloudy,  new  lamellae  of  lens 
fibres  are  deposited,  which  have  abnormal  shape,  position  and  transpa- 
rency. This  always  presupposes  that  the  productive  viability  of  the  epi- 
thelium of  the  anterior  capsule  and  along  the  whorl  has  not  been  disturbed 
by  the  formation,  of  the  central  cataract.  The  time  of  development  of  this 
form  of  cataract  is  placed  during  the  second  period  of  development  of  the 
lens;  hence,  about  the  sixth  or  seventh  week  of  foetal  life  of  the  human 
embryo. 

Arnold's  idea,^  that  the  lens  is  originally  cloudy  and  later  clears  up 
fiom  the  periphery,  must  be  dropped.  For,  as  has  been  shown  on  page  51, 
this  central  cloudiness  which  Fr.  Arnold  found  in  the  central  portion  of 
the  lenses  of  young  animals  is  due  to  the  presence  of  a  fatty  substance 
which  melts  at  a  low  degree  of  temperature,  and  this  snl)stance  is  only 
found  in  the  centre  of  young  lenses  where  the  temperature  is  reduced;  this 
coagulates,  and  the  centre  of  the  lens  becomes  cloudy;  whereas,  on  heating 
to  the  temperature  of  the  body,  the  lens  clears  up  again,  the  substance  re- 
turning to  the  fluid  state. 


2  Walter  von  Amraou's  .Tournal.   f.  d.    Chir.  and   Auficnlioilknndp.   XXXII, 
p.  524. 

3  Untersuchuugen  uber  des  Aujio  des  Mcuschen.  lS.",-_'.  p.  1.j4. 


176 

H.  Muller  ^  described  a  case  occurring  in  a  young  goat,  with  cataracta 
polaris  posterior  and  persistent  hyaloid.  But  he  was  so  taken  up  with  the 
description  of  the  posterior  polar  cataract,  that  he  simply  mentioned  the 
presence  of  the  cataracta  centralis  lentis. 

Carl  Hess  reports  an  exceedingly  interesting  congenital  anomaly  in 
a  chick  150  hours  old.°  The  essential  features  of  this  malformation  con- 
sisted in  a  delayed  and  incomplete  closure  of  the  lens  vesicle,  as  it  is  derived 
from  the  epithelial  plate.  In  consequence  of  this  incomplete  closure,  the 
lens  fibres  were  not  held  in  by  the  enclosing  capsule,  and,  undergoing 
hyperplasia,  found  an  exit  through  the  opening  in  the  ampulla:  as  a  result, 
the  normal  nutritive  conditions  were  markedly  disturbed,  and  a  diffuse 
disintegration  of  the  elongated  fibre  followed. 

This  description  is  exceedingly  interesting,  since  it  offers  us  an  ex- 
planation as  to  the  cause  of  certain  forn^s  of  congenital  cataracts,  which 
up  to  this  time  has  been  ])urely  speculative.  It  is  possible,  if  the  develop- 
ment of  the  chick  had  not  been  interfered  with,  that  later  on  this  lens 
vesicle  might  have  become  constricted  and  closed,  after  those  fibres  which 
had  grown  out  of  the  ampulla  had  totally  disintegrated,  and  a  hindrance 
to  a  closure  which  they  offered  had  been  totally  removed.  The  fibres 
within  the  ampulla  (those  which  later  on  would  have  formed  the  nucleus), 
would  also  have  disintegrated.  If  now,  later  on,  new  fibres  had  developed 
in  a  perfectly  normal  manner,  a  normal  cortex  would  have  formed  around 
a  diseased  nucleus,  thus  giving  us  the  picture  of  a  true  congenital  central 
(nuclear)  cataract.  Hess  further  suggests  the  intimate  connection  between 
this  form  of  cataract  and  zonular  cataract,  and  he  further  states  that  an- 
terior polar  cataract  could  easily  be  explained  as  the  result  of  a  delayed 
closure  of  the  lens  vesicle.  Spindle  cataracts  could  be  explained  in  a  like 
manner. 

2.   CATARACTA  POLARIS  ANTERIOR.  CATARACTA  CENTRALIS 

CAPSULARIS  ANTERIOR.  CATARACTA  CAPSULARIS 

PUNCTATA.  ANTERIOR  CENTRAL  CATARACT. 

CATARACTA  PYRAIMIDALIS.  CATA-  ■ 

PACTA  PYRAMIDATA. 

Frequently  we  find  a  small,  glistening,  white,  and  (as  a  rule)  round 
opacity  at  the  anterior  pole,  which  reflects  the  light.  This  opacity  varies 
in  size  from  that  which  is  Just  perceptible,  up  to  one  having  a  diameter 

4  Gesamruelto  Und  Ilintorlassono  Schrifton  Hornusgegeben  von  O.  Becker, 
1872,  Bd.  1. 

5"Zur  Pathology  und  ratliologisclu'ii  Anatoinic  Verschiedener  Staaar  For- 
men."    Graefe  Aicli..  XXXIX.  18SK3.  B.  1.  p.  183. 


177 

of  from  2  to  3|  mm.  At  times  tliis  wliitf  spot  is  smooth  on  tlie  surface; 
again,  it  may  extend  out  into  the  anterior  chamber  the  distance  of  a  milo- 
metre.  AVhen  the  pupil  is  contracted,  it  touches  this  on  all  sides,  whereas 
when  the  pupil  is  enlarged  it  always  remains  situated  in  the  centre  of  the 
same.  In  the  ''flat  varieties,"  if  they  are  not  too  small,  we  can  at  times 
demonstrate  l)y  focal  illumination  a  slight  folding  of  the  adjacent  parts  of 
the  capsule.  Those  which  extend  into  the  interior  chamber  are  known  as 
ratarada  pyrarnidalis  or  pi/nimiddhi.  Vwy  nftcn  the  cataractM  pyramid- 
alis  is  the  only  anomaly  of  the  eye.  In  such  cases  the  amount  of  vision  de- 
l)ends  largely  on  the  size  of  the  cataract,  and  the  conditions  of  its  adjacent 
parts  of  the  capsule.  Cases  have  been  repeatedly  observed  in  which  vision 
was  perfectly  normal.  More  frequently,  however,  it  is  associated  with  the 
opacities  of  the  lens,  such  as  cataracta  centralis.  Tn  all  such  cases,  atten- 
tion should  be  directed  to  the  transparency  of  the  cornea;  also,  careful  in- 
vestigation for  remains  of  a  pupillary  membrane  should  be  made. 

In  his  "Anatomic,"  Becker  divides  anterior  polar  cataracts  into  three 
groups — the  congenital,  the  acqnii'ed.  and  those  due  to  adhesions  between 
capsule  and  iris. 

a.  CATAKACTA  POLARIS  ANTKKIOR  (PYRAMIDALIS)  CON- 

(;enita. 

All  the  varieties  of  cataract  noted  at  this  point  are  capsulojr  cataracts. 
In  all  cases  of  congenital  anterior  polar  cataract,  the  lens  is  otherwise  nor- 
mally constructed.  Hence  the  cataract  must  have  developed  after  the  con- 
centric formation  of  the  lens  had  begun;  hence  in  the  third  period  of 
foetal  development,  possibly  at  the  close  of  the  second.  In  the  foregoing 
division,  attention  is  drawn  to  a  case  observed  by  Hess,  and  the  possibility 
of  a  late  closure  of  the  lens  vesicle  ])eing  the  cause  of  an  anterior  polar 
cataract.  Jt  appears  that  iieither  these  congenital  anterior  polar  cataracts, 
nor  the  acquired  forms  seem  to  interfere  with  the  further  growth  of  the 
lens,  and,  finally,  since  the  growth  of  the  lens  follows  as  a  result  of  indirect 
cell  division  of  the  anterior  epithelium,  a  partial  loss  of  this  epithelium 
can  not  interfere  with  the  further  growth  of  the  lens.  The  histological 
structure  of  these  capsular  catai'acts  (litTci-  in  no  wny  from  capsnlar  cataract 
as  already  described. 

The  capsule  itself  is  nol  diinvn  out  as  a  rcgulai-  one.  hut  seems  rather 
to  be  folded,  and  on  section  shows  vcit  pretty  jjictures.  Frequently  the 
base  of  the  pyramidal  cataract  is  lound,  and  extends  for  sonu^  distance  into 
the  lens  substance;  in  fact,  the  central  portion  sci'ms  to  extend  a  little 
deeper,  so  that  its  edge  appears  curved  and  distinc-t  again.st  the  surround- 
ing transparent   lens  substaiu-e.      Whov  there  is  a   constriction   near  the 


178 

anterior  capsule,  this  curvature  becomes  especially  marked,  and  it  appears 
as  though  this  constriction  were  the  cause  for  the  curvature  of  the  deeper 
layers  of  fibres.  At  times  one  observes  that  the  pyramidal  cataract,  as  well 
as  the  flat  ones,  are  continuous  with  a  sharp  process,  which  extends  back- 
ward into  the  lens  substance.  Such  forms  are  the  transitional  step  to  the 
formation  of  the  spindle  cataracts. 

h.  CATAEACTA  POLARIS  ANTERIOR.  (ACQUISITA).    ACQUIRED 
ANTERIOR  CENTRAL  CAPSULAR  CATARACT. 

The  aetiology  of  the  acquired  form  of  central  capsular  cataract  has 
been  the  subject  of  a  great  deal  of  study  and  investigation.  According  to 
Arlt,  it  develops  in  children,  seldom  in  adults,  as  a  result  of  a  perforating 
central  corneal  ulcer.  He  was  of  the  opinion  that  a  portion  of  the  exudate 
remained  adherent  to  the  capsule.  It  is  not  to  be  denied  that  this  can 
occur.  The  oases  of  cataracta  pyramidalis  in  which  a  shred  of  scar  tissue 
extends  from  the  cornea  to  the  capsule,  and  thus,  by  this  means,  draws  the 
lens  and  iris  forward  and  holds  them  in  this  position,  demonstrates  that 
scar  tissue  which  is  formed  by  cornea  and  iris  can  take  part  in  the  formation 
of  the  pyramidal  cataract.  This,  however,  is  not  necessary.  Schweigger 
convinced  liimself,that  corneal  ulcers  which  are  not  situated  in  the  centre  of 
the  cornea  and  perforate  may  give  rise  to  central  capsular  cataract.  Hulke 
(O.  H.  R.,  p.  189)  does  not  consider  it  necessary  that  a  perforation  should 
occur  in  order  to  give  rise  to  a  central  capsular  cataract.  Owing  to  the 
extreme  shallowness  of  the  anterior  chamber  in  the  child's  eye,  especially 
in  the  new-born,  a  simple  swelling  of  the  corneal  tissue  during  an  inflam- 
matory process  (as,  per  example,  in  bl.  neonatorum),  is  sufficient  to  bring 
the  lens  and  cornea  in  contact  (Mackenzie,  Ed.  IV.,  p.  469).  In  both  cases 
— either  where  the  aqueous  is  drained  off',  or  where  the  inflammatory  ir- 
ritation causes  a  contraction  of  the  pupil — only  the  centre  of  the  anterior 
capsule  is  permitted  to  come  in  contact  with  the  inner  surface  of  the  cor- 
nea, and  it  appears,  if  this  takes  place  for  a  sufficient  length  of  time,  it 
will  induce  a  hyperplasia  of  the  capsular  epithelium.  According  to  Knies," 
but  a  few  days  of  actual  contact  of  the  ])upillary  iH)rtion  of  the  capsule  of 
tlu!  lens  with  the  surface  of  a  corneal  ulcer  are  sufficient  to  t'ause  a  hyper- 
plasia of  the  e|)ithclium  on  its  inner  surface.  Knies  succeeded  in  examining 
this  hyperplasia  at  such  an  early  stage  that  the  cloudiness  only  sel  in  dur- 
ing the  hardening  process.  Deutschman's  statements  are  of  eciual  im- 
portance.    He  observed  that  in  acute  imiulcnt  processes  of  the  anterior 


6C.  P.  Anterior  und  ('.  Mor,s:ii;ni.    /flu'iidtM-s  Klin.  M..n:itsblattt'r.  ISSO.  Bd. 
XVIII,  p.  181. 


179 

segment  of  the  gl()])e,  only  the  [joriioii  <>['  the  «r|obe  corresponding'  to  the 
free  pupilhirv  area  was  affected  by  ilic  pus.  the  posterior  surface  of  the 
iris  protecting  the  remaining  portion  of  the  capsule  for  a  long  time,  un- 
doubtedly because,  as  a  result  of  i litis,  the  posterior  surface  of  the  iris  be- 
came adherent  to  the  capsule.  Deutsclinuin  further  ob.served  that  the  pro- 
duction of  a  chronic  inflammation  of  the  vitreous  likewise  caused  a  hyper- 
phisia  of  the  anterior  capsular  epitheliun\.  leading  1o  the  formation  of  a 
true  capsular  cataract. 

'J'lu'  local  and  circumscribed  area  of  development  of  the  capsular  cat- 
aract, all  favor  the  local  and  the  temporary  action  of  the  cause,  and  this 
is  to  be  found  in  the  contact  of  the  anterior  capsule  with  the  pathological 
products  of  the  corneal  ulcer.  As  a  result  of  direct  contact  of  the  cap- 
side  with  the  vascular  pupillary  margin  of  the  inflamed  iris,  and  with  the 
inflamed  and  vascularized  cornea,  a  portion  of  the  lens  .receives  its  nour- 
ishment as  it  did  in  foetal  life;  namely,  by  means  of  the  vascular  capsule. 
Here,  again,  the  epithelial  cells  receive  their  nutriment  directly  through 
the  capsule,  and  as  a  result  there  will  be  an  increased  production  of  cells; 
which,  since  it  will  be  in  excess  of  the  regular  development  of  fibres  at  the 
whorl  and  the  gradual  movement  of  the  entire  epithelium,  will  naturally 
lead  to  a  local  hyperplasia,  which  becomes  changed  into  a  capsular  cataract; 
which,  as  a  result  of  its  owai  products,  limits  its  own  growth.  The  various 
forms  of  punctate,  flat,  pyramidal,  congenital  and  acquired  central"  cap- 
sular cataracts,  are  but  ditjerently  developed  products,  of  the  same  process. 

Sight  must  not  be  lost  of  Hulke's  observations,  that  during  foetal  life, 
in  which  a  tnie  anterior  chamber  does  not  exist,  every  affection  of  the  cor- 
nea leading  to  swelling,  would  be  sufficient  cause,  to  excite  that  portion  of 
the  lenticular  epithelium  lying  in  the  pupillary  area  to  undergo  a  hyper- 
plasia. Hence  Becker  states  that  he  "'inclines  more  and  more  to  the  belief, 
that  both  the  congenital  and  the  acquired  capsular  cataracts  are  due  to  the 
same  cause." 

Though  it  is  the  rule  that  congenital  central  capsular  cataract  is  pres- 
ent on  both  eyes,  this  is  not  necessarily  always  the  case. 

c.  CATA1?ACTA  CAPSULAR] S  AXTEinOlJ.  (ACCKKTA.) 

There  is  a  variety  of  circumscribed  capsular  cataract,  which  occasion- 
ally comes  under  observation,  which  results  from  permanent  adhesions 
between  capsule  and  iris.  True  simple  synechia  seldom  lead  to  the  forma- 
tion of  capsular  cataracts,  which  are  occasionally  observ^ed  at  the  point 
where  the  remains  of  a  persistent  pupillaf}'  membi'ane  is  still  adherent  to 
the  capsule,  the  lens  being  perfectly  transparent. 


x8o 

3.  CATARACTA  POLARIS  POSTERIOR-VERA. 

The  differentia]  diagnosis  between  this  form  and  the  spuria,  was 
given  on  i)age  144.  Jn  reality,  the  diagnosis  was  made  between  the  latter 
and  posterior  cortical  cataracts,  as  observed  in  retinitis  pigmentosa  and  cho- 
roidal disease.  The  posterior  cortical  catarai-ts  will  be  considered  further 
along. 

Becker  states,  (Anatomy,  p.  123),  "that,  based  on  his  examination  of 
preparations  of  posterior  cortical  cataract,  he  considers  that  he  has  shown 
that  a  true  posterior  polar  cataract  may  result  from  a  stagnation,  (possibly 
a  coagulation),  of  the  tissue  fluids,  even  at  the  temperature  of  the  blood. 
(Page  20(5.)  He  also  reports  the  case  of  a  dcg.  where  the  diagnosis 
of  posterior  polai-  cataract  was  made.  In  both  eyes,  on  examination, 
the  foetal  fissures  w^ere  found  filled  with  Morgagni's  globules.  These, 
he  states,  one  would  not  assume  were  albuminous  globules  originating  from 
partially  destroyed  lens  fibres,  since  these  ended  in  the  well-known  man- 
ner, with  broadened  ends.  To  his  surprise,  as  far  as  the  fissures  touched  the 
capsule,  this  was  covered  with  a  beautiful  epithelium,  which  he  suggests 
might  be  an  anomaly  or  a  malformation." 

Knies  describes  a  true  posterior  polar  cataract  in  connection  with  a 
spindle  cataract.  Becker  states  that  "the  formation  of  a  true  posterior 
polar  cataract  in  man  would  undoubtedly  originate  during  the  third  period 
of  foetal  development.  Where  due  to  some  unknown  cause,  the  saggital 
fibres  of  the  second  period  remain  in  contact  with  the  capsule  and  poste- 
riorly prevent  the  new  fibres  of  the  third  period  from  coming  together 
from  opposite  directions,  and  pressing  these  saggital  fibres  toward  the  cen- 
tre, we  have  the  ideal  example  of  a  cataracta  polaris  posterior  vera.  Such 
a  case  has  been  anatomically  examined  by  Schirmer,  and  will  be  fully  de- 
scribed along  with  the  lamellar  catai'acts.     (Page  186.) 

CATARACTA  FUSIFORMIS.     SPINDLE  CATARACT. 

.\ssociated  with  one  or  more  forms  of  axial  cataract,  a  form  of  cloudi- 
ness occurs,  which  extends  through  the  entire  length  of  the  axis  of  the  lens. 
Amnion  mentioned  this  form.  Pilz  ^  was  the  first  to  give  it  a  more  accu- 
rate description  and  name.  h\  the  eye  of  a  boy  who  had  suffered  from  a 
scrofulous  conjunctival  disease,  he  found  an  anterior  polar  cataract  about 
the  size  of  a  pin-head,  and  going  out  from  this  a  cloudiness  which  extended 
backward  exactly  in  the  axis  of  the  lens,  simulating  very  murh  a  thread 
having  a  smoky  or  topaz  color. 

Whereas  tlic  cax'  of  I'ilz  was  most  ])i'ol)ab'ly  an  acniii-cd   I'oi'in.  Hecker 


7  Pathology  des  Krystallinsen  System.   Prag.   Viertelyahrschr..  1850.  1  S..  33. 


i8r 
observed  a  ease,  in  botli  eyes  of  a  vdimji-  man.  in  uliieU  a  ((iiiiplicated  eon- 
genital  spindle  eataraet  existed.**  This  extended  t'loni  iIk^  posterior  sur- 
face of  the  anterior  capsule,  exactly  in  the  pole  of  the  lens,  as  a  .solid,  and 
by  focal  illumination,  as  a  bluish  white,  non-transparent  process,  which 
gradually  widened  into  a  bluish  white,  very  delicate  and  veil-like  transpa- 
rent bubble,  enclosinti'  the  innermost  portion  of  tlu'  nnch'ns.  and  this,  con- 
tinuing again  beyond  tile  bu!)b]e  in  the  axis  of  tlie  lens,  a^^ain  hecomes  a 
solid  strand,  whicii  finally  attached  itself  to  tlu'  posterioi'  (■a|)snle.  Within 
this  transparent  bubble,  separated  from  it  by  transparent  lens  substance, 
was  a  characteristic  cataracta  centralis. 

Previously,  E.  Mueller  had  illustrated  and  described  cas<.'s  in  which 
both  spindle  cataract  and  zonular  cataract  were  )>resent  at  the  same  time. 
He  obsei'ved  a  case  where  three  sisters,  the  mother  of  whom  likewise  had  a 
very  high  degree  of  reduced  vision,  had  ton  alar  cataract,  and  in  three  eyes 
there  was  also  a  spindle  cataract  present,  'i'he  second  eye  of  the  youngest 
also  had  a  posterior  polar  cataract  which  he  attributed  to  an  obliterated 
central  artery. 

It  is  characteristic  to  find  a  central  cataract  fused  with  an  anterior  and 
posterior  polar  cataract,  as  in  the  ease  described  aljove.  At  tinu's.  in  con- 
nection with  the  globular  cloudiness,  there  may  be  a  number  of  cloudy 
lamellae  situated  moi-e  peripherically.  Knies  has  described  the  spindle 
cataracts  with  especial  care,  and  it  is  interesting  to  note  that  in  the  mother 
of  the  children  who  had  this  affection  he  found  incomplete  zonular  cataract 
on  both  eyes,  whereas  the  father  had  become  blind  as  the  result  of  consecu- 
iire  cataract.  (Eight  eye,  cataracta  tremula:  left,  cataracta  accreta). 
Since  the  eyes  which  have  been  examined  show  no  signs  of  foetal  disease, 
the  anomaly  can  only  be  ascribed  to  an  anomaly  in  the  development  of  the 
lens.  Above  all,  heredity  seems  to  favor  this  view.  Cases  in  whicli  the 
spindle-formed  cloudiness  gradually  goes  over  into  a  central  cataract  are 
explainable  on  the  theory,  that  at  the  time  when  the  concentric  arrange- 
ment of  the  lamellae  begins  (third  period  of  development)  the  product  of 
the  second  period  (which  does  not  clear  up,  or  which  possibly  only  later 
on  becomes  cloudy)  remains  adherent  to  both  poles  of  the  lens  capsule, 
so  that  it  becomes  impossible  for  the  new  lens  fibres  to  conu'  in  apposition 
at  the  anterior  and  posterior  pole,  but  remain  separated  l)y  this  cloudy 
strand. 

Leber  has  described  a  spindle  cataract,  which  he  produced  experiment- 
ally by  injuring  the  capsule  of  the  lens.^  His  investigations  con-oborate 
to  a  certain  degree  Knies'  views  in  reference  to  its  formation. 

8  Berichte  der  Wiener  Auffenlvlinik.  S.  9JM). 

9  Kernstaarartige  Trubung  der  liinse  nach  Verletzung  ihre  Kapsel  nebst 
Bemerkuugeu  uber  die  Entsteluuig  des  Stationaren  Kern  und  Schihtstaar's 
Uberhaupt.    Arcb.  f.  Optli.,  Bd.  XXVI,  1.  p.  28(;-289. 


1 82 

B. 

LA^IELLAR  CATAKACT.     (WTARACTA  PERI  NUCLBARTS. 
(  ATA HACTA  ZONULARIS. 

Ed.  von  Yager  ^"  ])re.<('iite<l  to  ns  the  topographical  rehitions  of  a 
variety  of  forms  of  stationary  cataract,  which,  though  known  hefore  his 
time,  were  explained  by  him  in  a  different  manner.  He  obsei-ved  a  uniform 
cloudiness  of  several  isolated  lamellae  of  the  lens,  which  at  a  certain  dis- 
tance therefrom  surrounded  the  centre  of  the  lens;  and  these  lamellae 
were  surrounded,  both  without  and  within,  by  transparent  lens  substance. 
"It  had  the  appearan.ce  of  a  bright  grey,  almost  transparent,  accurately 
bounded  cloudiness  of  the  lens,  of  exactly  uniform  size,  and  rounded  off  at 
the  edges,  having  a  thickness  of  from  1^  to  2"  in  the  midst  of  an  otherwise 
normal  lens  system,  and  a])peared  according  to  its  form  and  character 
like  a  very  faintly  saturated,  uniformly  clouded  cortical  cataract,  of  a  lens 
system  of  about  1^  to  2''  in  size."  The  examination  of  extracted  cataracts 
bore  out  his  observations. 

The  foll,»«'ing  year,  Von  Graefe  ^^  wrote  a  more  exact,  and,  at  the 
same  time,  an  almost  exh:ai>fstive  treatise.  He  jiointed  out  the  fact  that 
lameJJar  cataract,  as  it  is  now  known,  is,  of  all  the  varieties  of  c-ataract,  the 
one  which  develops  most  frequently  in  childhood.  Since  that  time,  the 
number  of  observers  of  lamellar  cataract  has  greatly  increased,  so  that  we 
are  now  in  a  position  to  divide  them  into  three  classes.^^ 

After  the  use  of  atropine,  one  observes  behind  the  pupil,  a  faintly  sat- 
urated cloudiness,  which  has  a  sharply  defined  line  of  demarcation  from  the 
adjacent  transparent  peripheral  lens  substance,  and  has  a  diameter  varying 
from  5  to  8  mm.  The  degree  of  saturation  of  tliis  cloudiness  gradually 
diminishes  as  it  proceeds  toward  the  centre  of  the  lens.  By  this  means  the 
zonular  cataract  is  most  markedly  differentiated  from  a  nuclear  cataract. 
In  the  latter,  the  cloudiness  becomes  more  saturated  as  it  proceeds  toward 
the  centre.  On  opthalmoscopic  examination,  the  entire  cloudiness  gives 
a  dark  retiex  and  is  sharply  defined:  whereas,  on  focal  ilhuuinaticui.  it  ap- 
pears grey,  and  the  centre  of  the  lens  gives  a  l)r()\vnisli  red  retiex.  The 
cloudiness  is  not  ('(pially  dilfiise  in  all  cases,  and  made  up  of  scarcely  rec- 
ognizable punctate  opacities;  but  there  may  he  two  hinicHac  (uu-  in  fi'ont 
of,  the  other  behind  the  nucleus,  mach'  up  of  a  variahK'  uuinhcr  of  radiallv 
placed  cloudy  striations.   Under  such  coiuliticnis,  the  lanu-lJar  cataract  bears 


10  Staar  und  Staaroijeraiioiu'ii.  isr.4.  S.  17. 

11  Arch.  Opth.,  I.  2.  'I'M. 

12  Vrv'^U   Licl.rcicli.  1.  c.  \K   4S(l. 


I  S3 
a  very  close  rcseiiiblaneo  lo  some  foniis  of  incipient  senile  ciitaraet,  only  in 
the  latter  these  radially  placed  striations  are  more  peripheric.  But  since 
transparent  lens  substance  is  found  between  these  striations,  they  ])ermit 
of  a  clear  insight  into  the  formation  of  this  variety  of  cataract.  One  is 
enaibled  to  see  through  the  anterior  convex  cloudiness  into  the  concave 
side  of  the  cataract  behind  the  nucleus. 

The  number  of  lamellae  involved  and  the  density  of  the  opacity  may 
vary,  so  that  one  may  meet  with  all  gradations,  from  the  scarcely  recog- 
nizable smoky  cloudiness  to  the  complete  opacity. 

This  latter  form  was  first  illustrated  by  Von  Amnion.i:!  and  also  descrilied 
by  AVeniek.iSa  Arlt  described  this  as  a  form  of  stationary  nuclear  <'ataraots  of 
youth.14  Von  Graefe  was  the  first  to  apply  V.  Yager's  anatomical  data  to  Arlt's 
stationary  niuleaivcataiact  and  since  tlien  the  existence  of  a  stationary  solid  nu- 
clear cloudiness  has  been  described.  So  that  even  Tetzer's  compendium  of  Arlt's 
Aegide,  places  these  two  forms  together.  Only  Hasner  still  contended  that  an 
independent  stationary  nuclear  form  could  occur.  Becker  draws  attention  to 
the  fact  tliat  the  density  of  the  cloudiness  may  be  so  great  as  lo  make  it  im- 
possible lo  decide  wliether  or  not  transparent  lens  substance  is  enclosed  in  the 
center  of  the  lens.  This  has  since  been  shown  to  be  true,  as  the  result  of  the 
anatomical  pathological  investigations  of  Schirmer,  presently  to  be  quoted. 

Von  Graefe,  Sichel  and  Ed.  Muller  were  the  first  to  describe  a  douhle  lamellar 
cataract,  the  last  named  even  a  triple  one.  It  is  seldom  observed  fully  formed. 
It  can  only  be  diagnosticated,  when  the  outer  cloudy  lamella  is  still  transparent. 
Frequently,  however,  we  observe  how  around  a  well  developed  lamellar  cata- 
ract, a  second  one  is  beginning  to  develop.  The  latter  is  evidenced  by  the  fact 
that  between  the  lamellar  cataract  and  the  equator  of  the  lens,  we  find  isolated, 
delicate,  fork-like,  cloudy  striations  ))eginning  to  penetrate  the  anterior  and  pos- 
terior cortical  substance.  On  focal  illumination,  one  observes  that  these  fork- 
like  striations  seem  to  ride  on  the  lamellar  cataract;  hence  they  have  also  re- 
ceived the  name  of  "ffirfers."  Such  p:ir1i:illy  cloudy,  more  peripherically  situ- 
ated, lamellae  may  likewise  remain  stati(»nary  in  this  condition. 

■Liebreich  has  illustrated  such  a  case.  These  riders,  however,  only  appear 
later  on,  and  are  significant,  in  tliat  tliey  foretell  that  the  stationary  cataract 
is  about  to  become  a  total  one. 

Finally,  Liebreich  drew  attention  to  the  fad.  ihat  the  lens  is  less  de- 
veloped in  volume  in  cases  of  lamellar  cataract. 

Lamellar  cataract  nearly  always  occurs  simultaneously  in  both  eyes. 
Where  trauma  leads  to  the  development  of  lamellar  cataract  on  one  eye, 
this  is  not  the  case.    Becker  states  that  a  case  of  monolateral  lamellar  cat- 


iSaAmmon  Zeitschrift,  III.  p.  480. 

13  Yager's  Atlas,  III,  Taf.  XIV.  Fig.  114. 

14  Die  Kraukheiten  des  Auge.  II,  S.  2.50. 


i84 

aract.  the  other  eye  remain iiio-  perfectly  normal,  has  never  been  observed, 
Schirmer  ^^  reports  a  case  which  is  especially  interesting,  since  the  cataract 
was  only  present  on  one  eye:  further,  while  under  observation,  the  cloudi- 
ness of  \\\v  inner  zone  increased,  the  originally  transparent  zonular  cataract 
being  changcil  to  an  opacjue  one,  {"nuclear  catnracf'),  and  because  there 
could  be  no  doubt  as  to  the  late  development  of  the  outer  cataractous  zone, 
this  having  developed  after  the  seventh  year,  and  while  under  observation. 
The  originally  healthy  eye  remained  so. 

Scfiinnrr's  Case  Xo.  T'.-C'o,se  Report.  Heinrieh  Erust,  aged  14  years,  was  first 
seen  in  this  clinic  in  his  seventh  year,  October  14.  1884.  At  that  time  the  diag- 
nosis of  zonuhir  cataract  on  his  right  eye  was  made.  This  was  of  moderate  size, 
sharply  defined,  and  permitted  the  transmission  of  light  through  the  center. 
V— fingers  at  1  mm.  The  left  e.ve  was  not  cataractous.  In  early  life  the  patient 
had  suffered  from  rachitis,  and  at  the  time  changes  could  be  observed  in  the 
cartilaginous  portions  of  the  ribs;  also  the  characteristic  anaraolies  of  the  teeth. 
An  iridectomy  was  made  downward  and  inward.    Vision  was  not  improved. 

The  boy  was  seen  again  June  7,  1891.  There  is  still  present  on  the  one  eye 
a  double  zonular  cataract,  the  inner  of  w^hich  is  totally  opaque,  and  according 
to  the  usual  nomenclature  this  would  be  designated  as  a  nuclear  cataract.  The 
lens  is  moderately  shrunken.  The  outer  not  very  opaque  zonular  cataract  has 
a  diameter  of  about  7%  mm.:  the  inner  at  41/0  mm.  Both  are  sharply  defined, 
but  their  contours  are  not  perfectly  circular,  but  more  or  less  wavy  or  protrud- 
ing. July  8.  1891.  Extraction  was  made  through  the  old  coloboma.  after  a  piece 
of  the  capsule  had  been  extrat>ted.  On  exerting  but  slight  pressure  almost  the 
entire  lens  was  successfully  extracted  w^ithout  the  loss  of  vitreous. 

The  cataract,  which  was  extremely  soft,  was  carefully  cut  in  halves,  and 
the  one  half  at  once  placed  in  a  60  per  cent,  alcohol  solution:  the  other  half  was 
examined  in  the  fresh  state.  On  transverse  section  one  at  once  recognized  the 
cloudy  rings,  and  that  which  is  still  more  important,  is  that  one  sees  at  a 
glance  the  center  of  the  lens  is  perfectly  clear  and  transparent.  Hence,  this 
is  not  a  nuclear  cataract,  notwithstanding  the  opaque  condition  'of  the  inner 
zone.  In  the  fresh  sections  one  finds  the  droplets  between  the  fibres,  the  num- 
ber and  size  varying,  according  to  the  location  from  which  the  section  is  made. 
They  are  very  numerous  in  particles  taken  from  the  cloudy  zone,  very  few  In 
the  trans|»arent  zone  between  the  two  cloudy  zones,  and  still  less  so  in  the 
nucleus. 

The  fibres  are  everywhere  smooth,  and  in  places  where  there  are  many 
droplets  they  are  wavy  and  swollen,  but  nowhere  are  they  serrated. 

The  hardened  portion  was  cut  in  sections.  Thick  sections  show  the  two 
cloudy  zones  very  distinctly,  with  the  transparent  interspace  between  them, 
also  the  clear  nneleus.   Under  the  microscope  one  finds  both  made  up  of  numer- 


l5Zur  Pathologische  Anatomic  und  Pathogenese  des  Centralstaars,  Graefe 
Arch,,  XXXVIII,  B.  4,  1891. 


1 85 
ous  minute  drops  lyiiiR  betwoon  tlic  fibres,  and  tlit'Sf  aro  markedly  mon-  nuiner- 
ous  and  smaller  in  the  inner  zone.  (».(K»iri  to  0.(MK{  mm.,  whereas  in  the  outer 
zone,  they  range  from  0.00<>  to  O.OO;^  mm.  Externally  the  rings  are  sharply  de- 
fined, whereas  inward  the  number  of  drops  is  markedly  decreased.  The  char- 
acteristic changes  are  noted  to  a  less  degree  in  the  nucleus  in  the  zone  between 
the  two  zonular  cataracts,  they  are  somewhat  more  numerous. 

ScliiriHor  reports  a  similar  case,  which,  owing-  to  the  rarity  of  tliis  con- 
dition, likewise  deserves  mention. 

Case  No.  VI.  Anna  Durch.  aged  17  years,  presented  herself  at  the  clinic 
with  a  double  zonular  cataract  in  the  right  eye.  The  outer  zone  was  ex- 
tremely delicate  and  transparent,  but  showed  no  defect  at  any  point.  This 
surrounds  very  closely  a  large  disc  6  mm.  in  diameter,  which  is  totally  opaque. 
The  patient  had  had  convulsions  in  childhood,  and  her  teeth  showed  the  anam- 
olies  described  by  Horner.  The  clinic  records  show  that  this  patient  had  been 
examined  twelve  years  previously,  and  the  diagnosis  reads:  ••Simple  zonular 
cataract/'  At  that  time  a  discission  was  done  on  tlie  left  eye,  and  at  present  a 
delicate  secondar.v  cataract  exists. 

Ill  this  same  paper,  Schirmer  reports  another  case  equally  important, 
because  it  throws  light  on  the  aetiology,  not  only  of  central  cataract,  but 
also  of  true  posterior  polar  cataract;  the  conditions  present  coinciding  en- 
tirely with  those  described  by  Arlt  ^^^  and  Tetzer  ^^  as  the  n.?iial  ones  for 
the  formation  of  a  central  cataract:  namely,  associated  with  congenital 
anomalies — in  this  case,  a  micropthalmus. 

The  anatomical  basis  for  the  nuclear  cloudiness  consisted  of  tine  drops 
which  so  completely  filled  the  centre  of  the  lens,  that  the  cloudiness  of  the 
fibres  could  be  made  out  with  difficulty.  "They  are  equally  dispersed 
throughout  the  cloudy  area;  external  to  this,  they  suddenly  cease  to  ap- 
pear. The  fibres  are  greatly  changed  and  transformed  in  the  most  pe- 
culiar manner.  The  physiological  changes  which  one  would  expect  to  find 
in  a  patient  ol  years  of  age  did  not  apjiear.  The  minute  droplets  are  ar- 
ranged as  described  in  previous  cases,  only  in  this  case,  owing  to  the  push- 
ing aside  of  the  central  cloudiness,  they  follow  a  .somewhat  irregular  course. 
The  interspace  between  this  zone  and  the  central  cloudiness  shows  but 
slight  changes.  Hence  here  we  find  enclosed  in  a  zonular  cataract  a  nuclear 
cataract,  an  intense  equally  difTu.se  cloudiness  of  the  centre  of  the  lens,  the 
anatomical  construction  of  which  is  analogous  to  the  changes  noted  in  the 
cataractous  zone  of  a  zonular  cataract. 

Xotwithstanding  the  ])cculiar  position  of  the  cloudiness,  this  is  a  cen- 
tral cataract.     Anatomical  examination  showed  that  the  oldest  lamellae  of 

16  Arlt-Krankheiten  des  Auge.  Bd.  IT.  p.  2.">0.    Prag.,  18.54. 

17  Compendium  der  Augenlieilkunde.  4  Aufl.,  S.  282.    Wien.  1887. 


1 86 

the  lens  were  alYected  bv  tlie  cataractous  process,  and  its  adlierenee  to  the 
posterior  capsule  explains  its  dislocation  posteriorly.  This  process  is  anal- 
ogous to  the  one  found  in  spindle  cataracts,  and  this  latter  form  is  found 
associated  with  zonular  cataract.  In  this  case  the  abnoi-nial  adhesions  did 
not  lead  to  a  drawing  out  of  this  to  a  thread,  since  this  adhesion  only  ex- 
isted at  the  posterior  capsule;  hence,  as  the  leaves  of  the  capsule  continued 
to  separate  farther  and  farther  from  each  other,  there  was  not  sufficient 
tension  exerted,  and  the  posterior  ends  of  the  fibres,  which  should  have 
pushed  themselves  in  between  the  posterior  and  the  central  cataract,  were 
apparently  not  strong  enough  to  stretch  this  adhesion,  which  seems  to  be 
a  possibility  where  the  adhesion  is  narrower,  as  shown  by  Knies.^^ 

Schirmcr'f^  Case  Xo.  IT.  George  Xaujoks.  .".(»  years  of  age.  born  of  healthy 
parents:  all  of  his  brothers  and  sisters,  except  a  stepsister,  died  in  early  child- 
hood of  diseases  unknown  to  him.  This  sister,  since  early  childhood,  can  only 
see  objects  which  are  in  close  proximity.  WJietliei;  tl«^  is  due  to  myopia  or 
interference  in  the  refracting  media,  am  unable  to  learn. 

Patient  states  that  he  never  had  convulsions.  Since  early  childhood  he  has 
only  seen  sufficiently  to  grope  his  way  about.  In  his  twentieth  year  iridectomy 
was  done  on  both  his  eyes,  and  vision  was  thus  somewhat  improved.  The 
left  eye  remained  in  this  condition  foi-  many  years,  and  only  lately  has  \  ision 
diminished.    Several  years  after  the  operation  the  right  eye  became  totally  blind. 

March  10.  1891.  Active  horizontal  nystagmus  on  both  eyes;  pronounced  mi- 
cropthalmus.  Right  eye,  artificial  coloboma,  downward  and  inward,  in  the 
middle  of  which  one  can  see  the  edge  of  the  shrunken  lens.  Left  eye.  the 
cortical  substance  is  totally  transparent,  with  the  exception  of  a  delicate  cloudi- 
ness downward  and  inward.  One  can  easily  discern  a  central  cloudiness  of  the 
lens,  which  appears  to  be  markedly  posterior  to  the  plane  of  the  iris.  This  can 
be  separated  into  a  central  yellowish  white  small  portion,  surrounded  by  a 
3  mm.  in  size  Avhitish  lamella,  which  everywhere  surrounds  the  edge  of  the 
Internal  cloudy  portion.  Both  are  sharply  defined;  their  contours  are  not  en- 
tirely circular,  but  here  and  there  show  slight  projections.  No  distinct  pictures 
of  the  fundus  can  be  obtained,  though  a  red  reflex  of  the  fundus  can  be  ob- 
tained tln-ough  the  periphery  of  the  lens.  There  is  also  a  very  delicate  diffuse 
cloudiness  of  the  cornea.    A'.— fingers  at  2V2  meters. 

Right  eye.  Conditions  altouT  the  sMiiie.  with  ;il>s(.lu1e  .•uiiaun.sis.  subse.nient 
to  a  very  active  chorio-retinitis. 

May  22,  1891.  Left  Eye.  A  discisioii  w.is  doii.'.  Veiy  slight  tumescenes 
and  slow  cloudiness  of  the  cortical  layers  followed.  Siii<e  in  the  course  of  a  few 
weeks  this  did  not  progress,  but  began  rather  to  clear  up  again,  an  extraction 
was  nijide  through  tlie  old  colobonia,  .Muie  30.  1891.     After  extracting  a  large 


18  Uber  Spindclsta.ir  und  dir  Ac-onmiodation  bei  DensellM>n.    Arch,  fur  Opth. 
XXIII.  1,  S.  217. 


i87 
piece  of  llie  capsule;  tile  si><)oii  was  iiit rodiiced,  and  the  cloudy  n\icleus,  together 
Willi  liie  cortex,  feiiioved:  and  the  i-eiiiaiiis  largely  removed  by  massage.  By 
.hiiie  IS.  l.SDl.  the  cortical  reiiiaius  were  lotalLy  resorlied.  so  that  the  impillary 
area  was  perfectly  free  hack  to  the  posterior  c:ipsule.  On  this  <-ouhl  be 
seen  (lisliiiclly.  ceiitr.ally  located  and  intensely  whit.-,  a  sni:ill  posterior  capsular 
cataract,  which  had  been  observed  shortly  stibse.nient  to  the  extraction;  like- 
wise, the  two  Maps  which  lie  closely  to  the  coloiionia  appear  greyish  white. 
Vision  with  +12  1».  ling.'fs  at  three  meters.  This  tliickeiiing  of  Ih.-  ca])snle 
^vas  extracted  with  but  slight  loss  of  vitreous. 

.Inly  15.  1891.  Course  of  healing  normal,  l.arge.  <lear  space  in  the  iniidl- 
lary  area.  The  capsule  was  examined  in  its  fresh  state  under  the  inieroseope, 
and  disclosed  a  wide-reaching,  capsular  cataract,  in  which  was  found  a  large 
(luantity  of  pigment  granules.  At  (»ne  circular,  cireumscript  spot,  on  top  of 
this,  is  found  a  conglomeration  of  most  peculiar,  short  cylindrical  structures, 
Avhich  are  irregularly  placed' one  over  the  other.  They  remind  one  of  greatly 
thickened  lens  fibres,  which  contain  large  numbers  of  small  and  large  albumi- 
nous drops,  and  then  attain  most  irregular  contours.  This  cireumscript  condi- 
tion and  microscopical  appearance  corresponds  jiosteriorly  to  the  <me 
noted  in  vivo  as  a  white  central  cloudiness.  Hence  tho'  belief  that  this  pe- 
culiar formation  is  the  remains  of  the  center  of  the  lens,  which,  as  the  exami- 
nation will  show,  was  adherent  to  the  posterior  cjii>sule  of  the  lens,  and  re- 
mained adherent  to  it  at  the  time  of  the  extraction,  .lud  assumed  this  peculiar 
change  as  a  result  of  its  contact  Avith  the  aqueous.  The  capsule  was  stained, 
imbedded,  and  cut  into. sections.  Sagittal  sections  showed  that  between  the 
above  spoken  of  remains  and  the  c:ipsule.  true  non-i)igniente(l  capsular  cata- 
ract tissue  existed.  The  two  flaps  likewise  contained  capsular  cataracts,  and 
the  pigment  undoubtedly  was  derived  from  the  iris.  From  this  it  follows  that 
the  pigment  only  entered  subsequent  to  the  extraction. 

The  extracted  lens  was  cut  in  half  in  the  fresh  state;  on  section  it  disclosed 
an  almost  globular,  intense  cloudiness,  I'l-  mm.  Avide  and  1  mm.  thick,  which 
borders  posteriorly  at  the  posterior  pole,  at  the  point  where  the  piece  of  cap- 
sule Avas  extracted.  It  gives  one  the  impression  :is  though  the  nucleus  had 
been  forcibly  pressed  backward.  This  cloudiness  is  further  sui-rounded  by  a 
second  cloudy  zone,  Avhich  anteriorly  is  separated  from  the  former  by  a  trans- 
parent zone,  whereas  laterally  it  is  directly  in  contact  with,  and  posteriorly 
entirely  Avanting. 

The  other  portion  w;is  imbedded  and  cut  intij  sections.  The  microscopical 
examination  offers  the  s.-uiie  expl.-mation  for  the  striking  position  of  the  central 
cataract.  In  fact,  the  entire  nucleus  has  been  dislocated  jiosteriorly.  The 
anterior  cortical  layers  are  es]»eci;illy  thick,  whereas  posteriorly  they  are  very 
thin,  and  ce:ise  at  a  certain  distance  from  the  posterior  pole,  so  that  at  that 
point  the  nucleus  lies  entirely  free.  The  study  of  the  etjuatorial  region.  Avhere 
the  fibres  turn,  is  especially  instructive  and  conclusive  for  this  condition.  The 
fibres  do  not  lie  as  in  the  normal  lens,  in  a  plane  which  is  slightly  bent  back- 


ward,  but  they  ouly  follow  their  normal  position  in  the  periphery;  the  older 
the  fibres  the  more  centrally  they  lie,  and  the  farther  back  their  point  of  bend- 
ing is  placed,  and  finally  they  border  on  tlio  equator  of  the  nucleus.  A  plane 
drawn  through  all  the  points  of  curvature  would  assume  posteriorly  a  very  de- 
cided funnel-shape,  facing  posteriorly,  as  though  the  nucleus  had  been  exerting 
traction  backward.  As  has  already  been  stated,  the  posterior  surface  of  the 
nucleus  is  centrally  perfectly  free,  simply  covered  by  an  albuminous  film,  and 
here  the  fibres  have  not  the  concentric  arrangement,  but  are  arranged  vertically 
or  almost  so,  and  are  torn  in  a  jagged  line,  along  which  are  numerous  sharp 
points.  This  in  connection  with  the  posterior  polar  cataract,  gives  us  the  ex- 
planation for  the  position  of  the  nucleus.  TJiere  was  an  adhesion  between  the 
oldest  fibres  and  the  posterior  capsule  of  the  lens,  which  at  this  point  held  the  nu- 
cleus fast,  and  offered  an  insurmountable  obstacle  to  new  forming  lamellae,  so  that 
these  could  derelop  normally  only  in  the  anterior  half  of  the  lens. 

Otherwise,  the  examination  disclosed  nothing  other  than  has  already  been 
observed  in  teased  sections.  The  zonular  cataract  shows  the  same  small  drop- 
lets coalescing  to  form  larger  ones  in  the  interspaces.  The  apparently  clear 
zone  between  the  cloudy  zone  and  the  central  cloudiness,  likewise  shows  sim- 
ilar formations.  The  outer  cortical  lamellae  are  normal  in  appearance,  the 
inner  show  signs  of  advancing  age.  Where  the  discission  had  been  done  the 
fibres  show  signs  of  disintegration. 

The  amount  of  vision  depends  on  the  density  of  the  cloudiness,  and  the 
equatorial  diameter  of  the  cloudy  lamellae.  It  may  occur  that  children 
with  douhle  lamellar  cataract  may  go  through  school  without  suffering  any 
material  interference  during  their  entire  school  life.  Becker  operated  a 
married  woman,  in  whom  a  lamellar  cataract  had  become  progressive,  and 
a  man  24  years  of  age  was  taken  up  in  the  clinic  for  the  same  reason.  The 
rule,  however,  is  that  the  defect  becomes  noticeable  when  the  studies  begin 
to  make  greater  demands  on  the  eye.  Hence  most  cataracts  come  under  ob- 
servation between  the  tenth  and  twelfth  year.  If  the  cloudy  lamellae  are 
very  centrally  located,  hence  especially  small,  the  eye,  where  there  is  a 
moderately  wide  pupil,  can  see  past  the  cataract,  and  the  degree  of  vision 
may  be  relatively  high.  Becker  very  carefully  examined  a  series  of  such 
cases,  three  at  Vienna,  and  in  all  of  them,  found  a  slight  degree  of  myopia. 
Owing  to  the  reduced  vision,  such  an  examination  offers  great  difficulties. 
Nevertheless,  eliminating  all  source  of  error  as  much  as  is  possible,  it  is  still 
possible  to  estimate  the  refraction.  On  using  atropine,  a  case  which  at  first 
was  myopic  was  found  to  be  hyperopic. 

Nearly  always,  the  condition  of  refraction  is  found  to  be  a  slight 
myopia,  and  the  width  of  accommodation  is  exceedingly  narrow. 

"With  the  exception  of  the  three  Vienna  cases  which  I  examined,  being  as- 
sisted by  Dr.  Schulek,  the  utmost  care  was  used  to  eliminate  every  source  of 


1 89 
error.  All  the  estimates  of  refraetion  were  made  with  the  opthalmoscope.  As 
a  rule,  no  staphyloma  was  found  at  llie  ent ranee  of  the  opiie  nerve.  l»ui  slight 
evidences  of  choroidal  atrophy  were  observed.  Aside  from  this  nothin-;  abnormal 
was  found  in  the  fundus.  The  overwhelming  occurrence  of  slight  myopia  with- 
out the  opthalmoscopic  evidences  of  a  myopic  eye,  can  be  explained  by  the 
spherical  aberration  of  the  lens,  since  all  the  rays  of  light  whicli  pass  near  the 
(•enter  of  the  lens  are  detiected." 

"Xevertheless.  the  myopia  may  be  acquired  in  ilie  usii.-il  way.  since,  owing  to 
tlie  i)oor  vision,  objects  are  brought  closer  to  the  eye.  In  tlie  eases  examined 
vision  varied  from  ^  to  j^^j,  and  was  lowest  in  liypermetropic  eyes.  With- 
out exception,  tlie  width  of  accommodation  is  reduced  in  eyes  having  lamellar 
cataract.  This  is  not  surprising,  since  one  does  not  have  to  go  far  to  under- 
stand that  in  cataractous  lenses,  even  where  the  cataract  is  partial,  that  but 
few  eyes  are  suitable  for  the  observation  of  processes  of  accommodation,  es- 
pecially where  the  iridectomy  is  made  for  lamellar  cataract:  hence,  the  results 
of  the  investigations  of  Coccius  19  are  to  be  critically  examined,  since  they  were 
made  on  just  such  eyes." 

Lamellar  cataract  occurs  almost  exclusively  on  both  eyes.  This  of 
itself  seems  to  indicate  that  the  causative  element  is  present  in  the  general 
condition  of  the  patient.  This  belief  is  .strengthened  by  the  fact,  that  fre- 
quently there  seems  to  be  an  hereditary  influence.  Hence  until  lately  it  re- 
mained an  undecided  question  as  to  whether  lamellar  cataract  is  congenital. 
Just  during  the  time  Becker  was  occupied  in  studying  this  subject,  a  child 
fifteen  weeks  old  was  brought  to  liim,  which  had,  in  both  eyes,  a  small,  but 
not  to  be  mistaken,  lamellar  cataract,  which  the  parents  observed  the  day 
the  child  was  born.  According  to  the  general  opinion,  however.  lamellar 
cataract  does  not  develop  until  after  birth. 

Von  Graefe  considered  it  a  fact,  that  during  the  first  years  of  life  this 
cloudiness  continued  to  increase  in  .saturation,  only  later  on  to  remain  sta- 
tionary. Hence  so  many  lamellar  cataracts  are  overlooked  during  the  earlv 
years  of  life. 

Great  credit  should  be  given  to  Arlt,  who  was  the  first  to  formulate 
our  ideas  as  to  the  aetiology  of  lamellar  cataracts,  and  he  was  the  first  to 
direct  our  attention  to  the  frequent  occurrence  of  lamellar  cataract  in  in- 
dividuals who  had  suffered  from  convulsions  in  infancy.  Horner  also  noted 
this  fact,  but  added,  that  many  also  suffered  from  deformities  of  the  teeth, 
of  the  cranial  bones,  and  were  mentally  weak.  In  the  ()5  cases  recorded  by 
Arlt  and  Horner,  in  48  cases  the  coincidence  of  lamellar  cataract  and  con- 
vulsions were  noted.  Horner's  36  cases  showed  deformities  of  the  teeth 
in  25  cases,  in  16  cas«s  anomalies  of  the  cranial  bones,  and  4  were  mentally 

19  Der  Mechanis  mus  der  Accommodation  des  Menschliehen  Auges.  Leip- 
sig,  18G8. 


190 

deficient.  In  1883  Max  von  Aix  20  reported  189  cases  of  zonular  cataract, 
observed  between  18(i.j  and  188;),  in  the  i)rivate  clinic  of  Prof.  Horner.  Of 
these,  107  (56.61  per  cent.)  had  had  convulsions  in  earliest  youth;  111, 
(66.07  per  cent.)  which  in  1865  were  designated  as  having  rachitic  teeth, 
60  (31.76  per  cent.)  showed  malformations  of  the  bones  of  the  skull,  con- 
sisting of  more  or  less  assvmetry;  40  (21.16  per  cent.)  showed  marked  signs 
of  rachitic  deformities  of  the  extremities.  In  153  cases  (80.42  per  cent.) 
the  patients  showed  at  least  one.  usually  two  or  more,  s3'mptoms  of  consti- 
tutional disease,  whereas  but  37  showed  absolutely  no  signs  of  rachitis.  In 
the  entire  statistical  table,  there  is  not  a  single  case  recorded  in  which  the 
characteristic  uveal  disease,  or  interstitial  keratitis  diffusa,  was  noted;  hence 
in  all  probability  zonular  cataract  is  the  result  of  rachitis,  and  not  syphilis." 
The  cases  of  multiple  lamellar  cataract  are  not  less  important  aetio- 
logically  than  the  above,  since  they  show,  owing  to  the  presence  of  the 
cloudiness  in  more  than  one  lamella,  that  the  cause  of  the  disease  must  be 
of  a  remittant  and  recurring  nature. 

Arlt  did  not  consider  lamellar  cataract  as  congenital,  but  imagined 
that  the  shock  which  the  eye  received  during  a  convulsion  was  sufficient 
to  cause  a  sliding  past  each  other,  as  it  were,  of  the  elements  of  the  lens, 
just  at  the  point  where  the  most  compact  and  heavy  nucleus  came  in  con- 
tact with  the  softer  and  more  delicate  cortical  substance.  This  change  in 
position  he  considered  sufficient  to  cause  a  cloudiness  of  the  lamellae  which 
lay  next  to  the  nucleus.  Becker  likewise,  basing  his  conclusions  on  Von 
Graefe's  three  cases,  where,  following  an  injury  to  the  eye,  the  lens  was 
dislocated  and  gradually  a  lamellar  cataract  developed,  and  one  of  his  own 
in  which  a  lamelhir  cataract  developed  after  a  trauma,  came  to  the  con- 
clusion that  this  form  of  cataract  may  be  due  to  trauma,  as  well  as  con- 
vulsions, the  lamellae  nearest  the  capsule  being  disturbed  in  their  nutri- 
tion, and  in  consequence  of  this,  becoming  cloudy.  Then,  again,  the  occur- 
rence of  a  number  of  lamellar  cataracts  could  be  brought  in  connection 
with  the  intermittent  cliaracter  of  the  convulsions.  The  inner  lamellae 
being  the  oldest,  depending  on  the  size  of  the  cloudy  zone,  one  could  to  a 
certain  extent,  determine  at  what  time  of  life  the  convulsions  occurred. 

Horner  laid  great  weight  on  the  fact  that,  aside  from  the  convulsions, 
other  signs  of  rachitis  could  be  found.  It  was  mainly  the  result  of  his  ob- 
servation that  attention  was  first  drawn  to  the  rachitic  form  of  teeth  found 
in  these  eases.  Owing  to  the  great  imi)()rtance  which  attaches  to  the  simul- 
taneous presence  of  this  ronii  of  teeth  i\iu\  this  fonu  of  cntai-aet.  1  (piote 
his  description. 


20"Zur  ratholojjie  de.s  Schkht  Sraars."    InauK-  Dissert,  unter  Horner. 


191 
"On  close  exaniinatlon  of  jin  incistT  tooth  one  will  observe,  in  a  perfect 
specimen,  that  the  enamel  gradually  tliins  off  toward  the  neck.    The  enamel 
is  shininjr  and  smootli.  and  on  focal  illumination  has  a  satiny  gloss.    This  satiny 
appearance  is  due  to  a  system  of  transverse  furrows,  wliicli  encircle  the  crown 
of  the  tooth.     The  less  completely  a  tooth  is  foriiieil,   liie  less   lliis   toolli   will 
show  this  wavy  finish,  and  by  close  observation  one  can  sec  tluit  tliis  is  due  to 
the  greater  distance  at  wliich  tliesc  furrows  are  one  from  anotlier.    Tliese  fur- 
rows may  be  exceedingly  delicate,  and  so  closely  packed  together  as  to  require 
a  magnifying  glass  1o  see  tliem;  and  again,  they  may  become  gradually  more 
distinct  and   coarser,   so  as   to   l)cconie  visil)le   to  an   olsserving  eye.      Now,   in 
rachitis   an   anoiiiiily   |>rcsciits    itself   wiiieli   is   easily   recognizable.      The   teeth 
are  plump  and  thicker.     Instead  of  the  elegant  chisel-shaped  teeth  we  find  them 
cubical  or  ill-shapen.     Nevertheless,   the  form  as  a    wiiole   may   resemble  the 
ideal.    The  most  interesting  feature,  however,  is  the  departure  from  the  normal 
of  the  surface  of  tlie  tootli;  the  enamel  instead  of  gradually  disappearing  to- 
ward the  neck,  nearly  always  ends  suddenly  in  a  tliickening.     The  above  men- 
tioned furrows  are  heajied   up  t(t  an  enormous  height;  sometimes   we  find,  es- 
pecially toward  the  cutting  edge,  instead  of  a  furrow,  in  the  same  place,  a  row 
of  round  holes,  as  though  they  had  been  gouged  out  with  an  awl.     Toward  the 
cutting  i^d'^e  the  body  of  the  tooth  terminates  with  a  convex  edge.     The  union 
of  the  lingual  and  the  labial  plates  of  enamel  are  joined  over  the  body  of  the 
tooth  in  irregular  or  .ingSfd  lamellae.     In  extreme  cases,  at  some  points,  the 
enamel  may  be  entirely  wanting,  and  mostly  in  such  a  manner  that  the  base 
of  the  denuded  spot  coincides  with  a  very  large  transverse  furrow;  while  in 
other  places  it  is  heaped  up  wave-like;  whereas  again,  at  the  cutting  edge,  it 
seems  to  be  washed  away.     The  denuded  bone  of  the  tooth  then,  as  the  result 
of  the  action  .of  the  damp  warm  air  in  the  mouth,  turns  brown,  in  striking  con- 
trast to  the  white  enamel.     Only  individual  teeth  seem  to  suffer  in  a  character- 
istic manner  from  this  anamoly,  and  these  seem  to  be  aft'ected  only  to  a  certain 
degree. 

'•In  contradistinction  to  this  anamoly  stands  the  one  due  to  hereditary  syph- 
ilis, and  which  occurs  almost  exchisively  on  tlie  ujtper  incisors,  and  appears 
even  in  the  permanent  teeth. 

"The  upper  teetli  are  short,  narrow,  their  angles  rounded  off.  and  their 
edges  exhibiting  a  broad,  shallow  notch.  Usually  one  or  two  teerh  converge 
toward  each  other;  in  other  cases  they  stand  apart  with  an  interspace,  or  they 
diverge.  The  simple  broad  notch  of  greater  or  less  degree  of  depth,  is  hardly 
ever  wanting.  The  teeth  are  almost  always  of  bad  color.  They  may,  however, 
in  some  instances,  be  of  very  fair  whiteness.  On  looking  carefully  at  the  sur- 
face of  the  notch,  there  is  almost  .always  the  evidence  of  wearing:  that  is.  the 
enamel  is  not  perfect  in  the  scooped  out  border  of  the  tooth."  21  Hence,  these 
teeth  seem  to  be  wanting  in  .iust  the  most  characteristic  point  in  differential 


21  Hutchlnson-Trans.  of  Pathological  Society  of  London.  Vol.  X,  p.  294. 


192 

diagnosis,  for  in  rachitic  teeth  we  tind  the  heaping  up  and  ridge-lilie  formation, 
ami  in  places  the  total  absence  of  the  enamel.  This  enamel,  like  the  lens,  is  of 
epithelial  origin,  anil  it  niiifit  certainly  appear  as  an  astonishing  fact  that  both 
should  show  a  zonular  nhnonnaJUy. 

Previous  to  this  time,  II.  Schmidt  had  drawn  attention  to  the  fact, 
that  in  youthful  individuals,  in  affections  of  the  teeth  in  whicli  there  was 
irritation  of  the  alveolar  branches  of  the  trigeminus,  not  infrequently  the 
near  point  became  further  removed  and  the  width  of  accommodation  nar- 
rowed. He  looked  upon  this  as  due  to  a  reflex  increase  of  intraocular  ten- 
sion. Lately,  he  has  attempted  to  explain  lamellar  cataract  by  referring 
to  an  interference  with  the  nutrition  of  the  lens  .'system,  due  to  teetliing, 
and  he  also  pointed  out  the  fact,  that  during  the  progress  of  glaucoma, 
opacities  invariably  develop  in  the  lens.  He  considered  himself  justified 
in  drawing  the  following  conclusions;  namely,  that  the  branches  of  the 
alveolar  nerves  reflexly  interfere  with  the  processes  of  nutrition  in  the 
eye  during  the  time  of  teething,  and  in  some  individuals  this  interference 
may  lead  to  the  formation  of  cloudiness  of  some  of  the  lamellae.  Thus 
Schmidt  attempts  to  connect  the  formation  of  lamellar  cataract  with  the 
development  of  the  teeth. 

In  reference  to  this  matter,  the  investigations  of  Arnold  have  led  to 
a  most  surprising  discovery,  and  supported  in  a  most  unexpected  manner 
the  views  held  by  Horner;  proving  that  the  simultaneous  occurrence  of 
lamellar  cataract  and  rachitic  tooth  formation  is  something  more  than  a 
coincidence.  Both  abnormalities  have  a  common  cause — ricketts;  and  it 
can  be  no  longer  a  matter  of  surprise  that  other  sequelae  of  this  disease, 
such  as  abnormalities  in  the  formation  of  cranial  bones,  convulsions,  etc., 
occur  in  the  cases  in  which  we  find  lamellar  cataract.  Further,  we  will  no 
longer  consider  convulsions  as  a  necessiiry  step  between  ricketts  and 
lamellar  cataract.  It  is  also, worth  noting,  that  the  time  of  the  development 
of  the  enamel  of  the  second,  or  permanent,  teeth  is  coincident  with  the 
formation  of  those  layers  of  the  lens  which  become  cloudy  where  lamellar 
catai-act  toiins.  The  permanent  teeth  alread  exist,  fully  formed  at  birth, 
and  gain  continuously  during  the  next  few  years  their  later  shape.  There- 
fore, during  the  time  of  their  greatest  development,  they  are  exposed  to 
the  action  of  the  same  noxious  influence. 

Up  to  1888,  Horner's  theory,  which  was  coincided  in  hv  Leber,22  was 
in  vogue.     .\t  that  time,  Beselin  2:^  ])ublished  the  results  of  his  microscop- 


22  "Kernstar-artige  Trubiuig  der  Linse  naeh  Verletzung  ihre  Kapsel."  etc. 
(iraefe  Arch..  XXVI,  B.  1.  p.  283,  1880. 

23  "Kin  Fall  von  e.xtralnrtern  und  microscopisch  uutersiu'ht«Mn  Scliichstaar 
einer  Krwaehsenen."    Arch,  fur  Augenh.,  Bd.  XVIII,  p.  71,  1888. 


193 
ical-aiiatomical-pathological  cxainiiiatiori  of  a  case  of  lamellar  cataract,  in 
which  he  claimed  that  it  was  formed  just  as  in  the  senile  cataract.  Jlc 
states  that  he  not  only  found  fine  continuous  splits  between  nucleus  and 
cortex,  which  he  considered  the  anatomical  substratum  of  lanu'Uar  cata- 
ract, but  also  changes  in  the  nucleus,  which  was  hlled  with  a  great  number 
of  minute  splits  and  interspaces,  all  of  which  were  filled  with  granular  mat- 
ter. Though  he  considered  the  changes  in  the  nucleus  of  post  mortem 
origin — whereas  he  looked  upon  the  large  concentric  splits  as  having  oc- 
curred during  life — from  this  he  believes  that  he  can  positively  conclude  that 
they  are  due  to  the  chemical  change  of  the  nucleus  tvhich  leads  to  its  more 
active  shrinkage.  The  new-formed  outer  lamellae  can  not  follow  the  con- 
tracting nucleus,  but  separate  from  this,  hence  the  development  of  the 
interspaces  between  the  two — and  these  interspaces  are  the  expression  of 
what  is  known  as  zonular  cataract. 

The  essentially  new  part  of  JBeselin's  theory  is  the  assumption,  that 
the  detrimental  cause,  at  the  time  it  is  exerting  its  influence,  affects  a 
fully  formed  lens;  and,  secondly,  that  the  cloudy  zone  is  not  the  imme- 
diate result  of  the  detrimental  cause  nor  produced  at  the  time  of  its  action, 
but  only  follows  later  on,  as  the  result  of  the  shrinkage  of  the  nucleus. 
This  is  not  in  keeping  with  Deutschman's  statements,^*  who  found  the 
nucleus  unchanged,  and  who  likewise  coincided  with  Horner's  theory. 
Lawford,^^  who  examined  three  cases,  likewise  states  that  he  found  the 
nucleus  changed  and  found  splits  and  interspaces.  He  does  not  state  that 
he  agrees  with  Beselin's  theory,  but  states  that  he  looks  upon  the  forma- 
tion of  tine  splits  running  concentrically  to  the  surface  of  the  lens,  and 
between  the  nucleus  and  cortex,  as  the  cause  of  lamellar  cataract. 

As  the  result  of  his  examinations,  Schirmer  -*'  states  that  in  four  cases 
which  he  examined  he  found  three  constant  conditions:  First,  a  totally,  or 
almost  totall)',  normal  cortical  substance;  second,  beneath  this,  what 
microscopically  appeared  as  a  cloudy  ring  running  parallel  to  the  surface 
of  the  lens,  a  layer  of  compactly  arranged  minute  interspaces,  and,  finally, 
similar,  but  larger  and  less  frequently  distributed  interspaces  throughout 
the  nucleus.  Microscopically,  a  sharp  line  of  demarcation  did  not  exist, 
but  the  transition  from  the  large  to  the  minute  interspaces  is  quite  rapid. 

In  this  work  of  Schirmer's  and  the  one  quoted  above,  and  frotn  whicli 

24  "Pathologische  Anatomische  Untersuchnngren  eines  Menschlichen  Schicht- 
staars."    V.  Graefe's  Arch.,  XXXII,  B.  2,  p.  295,  188G. 

25  On  the  Pathological   Anatomy  of  Lamellar  Cataract  or  Zonula.     Royal 
London  Hospital  Reports.  Vol.  XII.  Part  II.  p.  184.    1888. 

26  "Zur  Pathologischen  Anatomie  uud  Pathogenese  des  Schiclitstaars." 
Graefe  Arch.,  Vol.  XXXV,  B.  3,  1889. 


194 

the  east'  rtixuls  are  lakcii,  ilic  \\\n>\  inddcrn  views  (•(»iiccriiin<i-  the  aetiology 
and  pa-thogt'iiois  of  tlii>  fniin  of  cataracl  and  il.-  rehition  to  central  cataract 
are  expressed.  A  iiiiinlxT  tif  later  iiivesti.iiatois.  Bernhard  Duh,^^  Carl 
Hess,28  and  Albert  I'eters."'  though  ditTei-iiig  with  him  in  some  minute 
details,  essentially  agi'ee  with  him — hence  Schirmer's  views  e.\[)ressed  in  his 
later  work.*'  are  (pioted  in  Jidl. 

"In  accord  with  Iloiiier"s  iheorv.  1  conceive  that  a  zonular  cataract  is 
due  to  the  action  of  a  passing  noxious  pi'iiiciph'  whicli  manifests  itself  hy 
the  formation  of  little  dro])lets  in  the  lens  as  it  exists  at  that  particular 
time.  The  droj)lets  appear  in  greatest  numhers  in  the  youngest  lens  fibres 
and  lamellae,  so  that  '-linically  we  lind  a  demoiist  rahle  cloudiness; 
whereas  the  oldest  fibres,  in  which  less  interchange  of  products  is  going  on, 
are  but  slightly  affected,  and  microscopically  these  latter  show  no  change. 
The  fibres  which  form  later  do  not  suffer  in  their  normal  transparency. 
This  explains  in  a  ])erfectly  rationally  manner,  why  it  is  that  the  cloudy  zone 
in  lamellar  cataract  has  the  foiiii  of  the  lens,  that  the  intense  cloudiness 
is  confined  to  one  sheath  (as  it  wvw).  and  show  but  slight  changes  in  the 
nucleus.  In  very  early  foetal  life  the  lens  is  not  only  smaller,  but  much 
more  globular  than  at  birth.  Tfence  a  zonular  cataract  which  forms  very 
early  in  life  will  not  only  be  smaller,  but  must  be  nuire  globular,  than  where 
formed  in  extra-uterine  life.  At  such  an  early  period  of  development  the 
fibres  throughout  the  entire  lens  possess  an  equal  amount  of  life,  and  all 
demand  an  equal  amount  of  nutrition:  at  this  time,  they  do  not  as  yet 
exist  as  fibres,  which  are  changed,  shrunken  and  removed  from  the  action 
of  the  nutritive  processes.  This  same  noxious  principle,  which  later  on 
simply  affects  the  youngest  lamellae,  causing  these  to  beconu'  cloudy  and 
only  slightly  affects  the  central  portion  of  the  lens,  which  is  I'emoved  from 
the  influence  of  the  nutritive  processes,  here  affects  the  entire  lens,  leads 
to  a  foetal  total  cataract,  over  which  gradually  new  transparent  lamellae 
are  deposited,  and  thus  in  time  a  central  lens  cataract  is  formed." 

Hence  the  theory  of  the  pathogenesis  of  zonidar  cataract  can.  without 
further  discussion,  be  adopted  for  central  cataract,  ami  the  following  state- 
ments apply  to  both  forms: 

'^\ny  noxious  principle,  the  exact  miture  of  which  is  as  yet  uid<nown, 

27Beltrage  zur  Kentniss  .Icr  Cataract  Zoiuilaris.  Ciaefe  .Vicli..  XXXVII. 
Vol.  IV.  3891. 

'■ix'/AW  I'atlH)lo.ui<"  niKl  I'atliolotiisdie  Aiiatoniie  ViTscliiedeii  Slaarformeu. 
•  iraefe  Anli..   NOl.   XXXIX.    1'..    1.  !>.  IS;'..     lS<t;;. 

29  T'hpr  (lie  Kntsteliunii-  des  Scliiclilstaars  uiui  Vi'i  waudte  Slaarfornien. 
rJraetV  Arch..  Vol.  XXXIX.  K.  2,  p.  221.    1S03. 

:'.0"/m-  rMtlioloirische  Anatoinie  niul  PalhojXfuese  ties  Ceiitralsiaars.  (;raefe 
.\i<li..   Vol.   XXXNIII.  T..  A.  p.   1.     is'.n. 


195 
will,  ill  all  ])r()l);il)ility.  intcrlVrc  with  the  ])rnpor  mitrilioii  of  the  lens  and 
in  the  lamellae  already  formed  at  the  time  of  its  aetion,  as  well  as  in  those 
just  forming.  'IMiese  changes  lead  to  the  formation  of  minute  dro])s,  which 
in  the  beginning  are  ])r()hab]_v  in  the  lihres.  hut  which  later  on,  as  these 
shrink,  are  pressed- out;  it  is,  however,  possible  that  tliey  were  out.?ide  the 
fibres  from  the  beginning.  Only  those  fibres,  which  are  fully  alive  and 
still  in  the  midst  of  the  nutritive  processes,  at  the  time  this  noxious  prin- 
ciple is  acting,  contain  such  numbers  of  minute  drops  as  to  lead  to  a 
clinical  cloudiness,  the  older  fibres  depending  on,  to  how  great  an  extent 
they  ])articipate  in  the  nutritive  processes  are  proportionately  affected. 
The  cause  for  the  formation  of  this  form  of  cataract  seems  to  abate  quite 
suddenly,  as  attested  by  the  sharp  line  of  demarcation  which  exists  between 
the  opaque  and  transparent  zone. 

"Depending  on  the  time  and  intensity  of  the  action  of  the  noxious  prin- 
ciple, an  entire  series  of  varieties  of  cataract  may  develop.  At  one  end  of 
the  series  is  the  small  white  globular  central  cataract;  at  the  other  re- 
stricted to  but  a  few  lamellae  is  the  very  delicate,  large,  almost  transparent 
zonular  cataract.  The  former  ai'e  due  to  a  very  decided  and  very  early  in- 
terference with  nutrition— (as  is  universally  conceded,  central  cataracts 
are  congenital)— the  latter  are  due  to  a  very  low  grade,  and  relatively 
late,  disturbance.  Zonular  cataract  appears  to  be  developed  at  birth,  but 
probably  developes  more  frequently  in  extra-uterine  hfe,  and  as  to  how 
late  in  life  this  may  develop,  the  above  cases  of  zonular  cataract  demon- 
strate. Between  these  two  forms  are  ranged  the  large  cataracts,  which 
show  the  configuration  of  a  zonular  cataract  and  are  totally  opaque." 

'Tt  is  true  that  a  similar  pathogenesis  for  both  forms  of  cataract,  is  no 
proof  of  a  similar  causation,  for  there  does  not  appear  to  be  such  a  great 
difference  as  Schnabel  coutends.^i  Schnahel  contends  that  nuclear  cata- 
racts, as  well  as  punctate  and  congenital  total  cataracts,  are  due  to  an  ab- 
normal condition  of  the  original  epithelial  germ,  whereas  zonular  cataract  is 
due  to  disturbances  occurring  in  intra  or  extra-uterine  life."  As  proof  of 
this,  he  states  that  one  frequently  finds  nuclear  cataracts  in  different  mem- 
bers of  the  same  family,  or  in  various  generations  of  the  same  family,  but 
zonular  cataract,  never!  Hirschberg  adds  a  note  to  this  reference,  stating 
that  he  has  operated  grandmother,  mother  and  child  for  zonular  cataract 
and  that  he  has  also  seen  similar  forms  in  mother  and  son;  and  other 
opthalmologists  likewise  have  had  the  same  experience.  Opposed  to  this 
latter  view,  one  must  mention  Knies'  spindle  staar  family.     Three  brothers 

3i"Vortrag  Gehalten  in  der  .Sitzung  dos   Voreins  der  Aerzte  Steiermarks," 
November  24,  1890.     Referat  in  Centi-alblatt  fur  Augenheilkunde,  April,  1891.' 


196 

had  central  cataract,  together  with  a  simple  or  double  zonular  cataract. 
Since  anomalies  of  the  lens  existed  in  the  three  sisters  of  these  brothers,  in 
their  mother,  and  the  mother's  grandfatlier.  this  case  does  seem  to  indicate 
some  abnormal  condition  of  the  original  epithelial  germ.  But  to  me,  not- 
withstanding the  larger  number  of  members  of  one  family  so  affected,  it 
does  not  prove  an  abnormal  condition  of  the  lens  germ,  but  leads  rather  to 
the  assumption,  which  I  believe  is  justifiaible,  that  this  is  due  to  a  general 
dyscrasia  (rachitic  disposition?)  in  the  original  germ,  Avhich  is  inherited, 
and  that  the  anomaly  of  the  lens  is  secondarily  induced  by  the  former.  It 
is  undoubtedly  true  that  central  cataracts  are  especially  frequently  found 
associated  with  other  congenital  anomahes  of  the  eye,  but  it  is  undoubtedly 
likewise  true,  that  at  times  its  formation  has  the  same  underlying  basis  as 
a  zonular  cataract.  Therefore,  I  do  not  believe  that,  generally  speaking, 
we  can  accept  Schnabel's  axiom.  As  he  expresses  it,  it  can  not  be  sustained, 
but  rather,  zonular  cataract,  as  well  as  central  cataract,  may  be  due  to 
various  causes.  Both  may  be  due  to  abnormal  conditions  of  the  original 
lens  germ,  but  also  to  intra-  or  extra-uterine  disturbances." 

It  is  impossible  to  draw  a  sharp  line  of  demarcation  between  zonular 
and  central  cataract. 

C. 
A  VAEIETY  OF  FOEMS  OF  CONGENITAL  PARTIAL  CATARACTS. 

There  is  probably  no  portion  of  the  lens  in  which,  at  some  time,  a  cir- 
cumscribed opacity  has  not  been  observed,  and  which  does  not  change  its 
relative  position  and  size.    A  whole  series  of  such  have  been  observed. 

a.   DOTTED  CATARACT.  CATARACTA  PUNCTATA.  CATARACTA 

COERULA.  CATARACTA  SENILIS  PRAEMA- 

TURA  PUNCTATA. 

This  form  of  cataract  is  seldom  seen,  because  it  is  usually  overlooked. 
Liebreich  was  the  first  to  accurately  describe  it.^-  In  his  "Anatomy  of  the 
Lens,"  page  174.  Becker  considers  this  form  of  cataract  along  with  the 
coiistitutional  cataracts,  and  designates  it  as  eataraeta  senilis  praematura 
punctata.  He  says,  "Constitutional  diseases,  especially  albuminuria  or  dia- 
betes, may  be  excluded.  I  have  not  examined  for  phosphaturia.  Syphilitic 
infection  as  a  rule  was  not  denied.  The  peculiarity  lies  in  the  presence  of 
circumscribed  punctate  cloudy  areas  in  the  anterior,  rarely  in  the  posterior 
cortical  substance,  and  their  excessively  slow  increase  in  size. 

"I  had  a  typical  case  under  observation  for  fully  thirteen  years.    It  begins 

32Nouveau  Dictionaire  de  Modieine  et  do  Cliirurgie  Prat.,  par  .T.  K.  Barlliere 
et  Fils,  yi,  p.  4S0. 


197 
with  uiiuuU'  i)Uii(tate  iip.uilit  s  nc.ii-  \hv  autoriDr  caiis^iilf.  In  the  course  of  the 
following  four  or  five  years  other  opacities  were  added,  until  the  entire  an- 
terior and  posterior  cortical  substance  was  permeated  with  tliem.  In  the  tenth 
year  cloudy  strealvs  first  began  to  develop,  until  finally,  owing  to  the  cloudiness 
of  the  entire  anterior  cortex,  the  cataract  loolced  lilce  a  senile  cataract,  with  a 
yellowisli  wliitc  nucleus  and  l)lueisli  wliite  cortex.  Tlie  patient  was  operated 
on  in  lier  forty-eighth  year,  and  altliougli  healthy  was  prematurely  old;  6-6 
vision  was  obtained.  I  make  this  statement  because  it  goes  to  show  tliat  the 
posterior  segment  of  the  eye  was  healthy." 

I)i-.  W'nIdhaiM'i-.  ^r.p  states  that  in  900  oases  operated  for  cataract,  he 
fouiul  two  of  this  vai'iely  and  neither  had  constitutional  disease.  lie  also 
reports  the  case  ol'  a  colleague  suifering  from  Bright's  disease,  operated 
by  Aon  Graefe  in  1860. 

Dr.  Carl  Hess  ^'^  exauiiiu'd  eleven  cases  clinically  and  six  anatomically. 
He  gives  the  following  description:  "All  showed  small  circular,  sharply  de- 
fined cloudy  areas,  the  largest  of  which  did  not  appear  to  have  a  greater 
diameter  than  1  mm.  and  are  found  in  the  perinuclear  lamellae,  and  de- 
crease rapidly  in  numbers  as  they  approach  the  poles.  They  seem  to  be 
more  numerous  in  the  anterior  cortical  substance  than  in  the  posterior.  As 
a  rule,  they  are  differentiated  from  the  usual  grey  spiculae  of  grey  cataract 
by  their  greyish  green  color.  In  all  eases  the  equatorial  region  is  as  good 
as  free  from  these,  or  completely  clear  and  transparent.  In  some  cases  the 
spiculae  of  grey  cataract  may  be  added.  The  age  of  the  patients  varied  from 
34  to  (i4  years,  and  all  the  cases  were  characterized  by  this  exceedingly 
slow  development.  General  diseases,  such  as  albuminuria  and  diabetes, 
could  not  be  discovered.  In  all  cases,  vision  was  such  as  to  permit  of  con- 
cluding that  the  condition  of  the  retina  was  normal." 

'•In  all  cases  the  lens  was  easily  extracted,  though  the  usual  clinical 
signs  of  a  ripe  cataract  were  wanting,  the  peripheral  cortical  layers  still 
being  totally  transparent.  From  this  we  may  conclude  that  there  existed 
an  unusual  consistence  of  the  cortical  lamellae  in  a  relatively  young  indi- 
vidual. In  all  his  cases  which  he  examined  anatomically,  he  found  these 
to  be  elliptical  s])aces  filled  witli  homogenous  or  very  finely  granular 
masses." 

Hess  divides  this  form  of  cataract  into  two  varieties — the  congenital 
and  the  acijinrcd. 

He  made  the  first  anatomical  examination  of  the  congenital  variety, 
the  clinical  history  showing  that  both  mother  and  daughter  had,  besides 


33  "Zwei  Falle  von  ('.  Punctata."   Graefe  Arch.,  Vol.  XXXI,  Bd.  1,  p.  249. 

34  "Z(u-  Pathologic  und  Pathologischen  Anatomie  Yerschiedenen  Staar  For- 
men."    Graefe  Arch..  Vol.  XXXIX.  Bd.  1,  p.  183.    1893. 


198 

this  condition,  a  central  cataract.  He  states,  "Close  to  the  nucleus  irreg- 
ularly distributed  spaces,  filled  with  granular  masses,  were  found,  which 
did  not  take  up  the  haematoxylin  stain  satisfactorily.  The  fibres  sur- 
rounding these  spaces  were  more  or  less  "gnawed  at."  From  this,  he  states 
that  he  feels  justified  in  assuming  that  the  congenital  form  is  anatomically 
essentially  different  in  its  character  from  the  acquired. 

For  the  acquired  form  he  assumes  that  the  lentiform  spaces  were  pre- 
formed, but  did  not  lead  to  any  disturbance,  being  filled  with  clear,  trans- 
parent fluid.  The  punctate  cloudiness  followed,  where  this  fluid  underwent 
a  chemical  change,  possibly  a  coagulation.  He  further  suggests  that  these 
eliptical  spaces  might  result  from  an  irregular  shrinkage  of  the  nucleus, 
but  it  must  be  remembered  that  they  are  arranged  in  a  special  portion  of 
the  lens,  "abnormal  structural  conditions  of  the  perinuclear  lamellae.'' 

b.  OATARACTA  STELLATA. 

According  to  Liebreich,  this  is  a  special  variety  of  cataracta  punctata. 
Hasner  described  two  such  cases,  and  illustrated  one.^^  His  description 
coincides  with  that  of  Liebreich.  It  was  observed  to  be  nearer  the  an- 
terior pole,  and  had  a  much  more  complicated  figure;  whereas,  in  cataracta 
punctata,  the  opacities,  as  they  approach  the  poles,  form  a  three-pointed 
star-figure,  forming  angles  of  120  degrees.  At  the  anterior  pole  this  figure 
forms  a  Y,  and  at  the  posterior  pole  this  is  turned  at  about  60  degrees. 
In  the  cataracta  stellata  the  figure  is  a  more  complicated  one;  the  radii  are 
but  60  degrees  apart,  and  from  these  a  second  series  extend.  Becker 
sitates,  that  he  observed  a  very  pronounced  case  at  Arlt's  clinic. 

CHAPTER  YII. 

CATAEACTA  ACCEETA.  CATAEACTA  COMPLICATA. 

In  consequencr  of  direct,  permanent  contact  with  diseased,  firm,  vas- 
cular, normal  or  paihologically  clianged  portions  of  the  eije.  the  tens  becomes 
cataractous — cataracta  complicata. 

All  forms  of  cataract  belong  here  which  occur  in  consequence  of  dis- 
ease of  the  retina,  or  the  formation  of  extensive  cyclitic,  irido-cyclitic  or 
iritic  bands  of  new-formed  connective  tissue.  Hence  the  causative  diseases 
are  detachment  of  tiio  retina,  iutra-oculav  tumors,  glaueoma  absolutum, 
cysticercus,  cyclitis,  iridocyclitis,  and  the  unknown  changes  which  lead  to 
buphthalmus  and  otlier  ectatic  processes  in  the  eye. 

I\\anoff  was  the  first  to  make  anatomical  examinations  of  this  form. 

35  Klinische  Vertrage,  p.  270.   1866. 


199 

In  all  these  cases  the  cellular  liy|)ri'i)lasia  is  incited  l)v  Ihc  aljiionnally  con- 
stituted nutritive  fluid  which,  though  entering  along  the  normal  channels, 
is  derived  from  a  pathological  vitreous.  Further,  the  continued  contact 
of  the  lens  with  vascular,  normal  or  pathological  structures,  even  in  a  cir- 
cumscribed Area,  will  once  more  incite  the  embryonal  mode  of  nourish- 
ment. 

A  number  of  cases  will  serve  to  illustrate  these  points: 

INCIPIENT  TOTAL  CLOUDINESS  OF  THE  LENS,   THE   KESULT  OF 
ADHESIONS  OF  THE  LENS  WITH  A  GRANULOM  OF 
THE  IRIS. 

In  consequence  of  a  granulom  of  the  iris,  adliesious  formed  between  the 
pathologically  changed  iris  and  the  capsule  of  the  lens.  As  far  as  this  adhesion 
extended  a  capsular  cataract  and  folding  of  the  capsule  liad  followed,  and  along 
the  equatorial  line  large  vesicular  cells  had  developed,  whereas  the  remainder 
of  the  lens  remained  transparent.  No  doubt,  with  the  growth  of  the  new  forma- 
tion, the  extent  of  the  lenticular  cloudiness  would  have  increased. 

CATARACTA  COMPLICATA  (BUPHTHALMUS). 

H.  Z.,  a  boy  8  years  of  age,  was  taken  up  at  the  clinic  June  13,  1878.  The 
right  eye  was  emetropic,  V  equal  to  6-6.  Regarding  the  left,  the  parents  state 
that  when  the  boy  was  one  year  old  they  began  to  notice  that  this  eye  was 
larger  than  the  right.  At  the  age  of  seven  years  Dr.  Pauli,  of  Landau,  saw  the 
child,  and  found  buphthalmus,  trembling  of  the  iris,  floating  opacities  in  the 
vitreous,  amaurosis.  Owing  to  the  opacities  in  the  vitreous  the  fundus  could 
not  be  studied.  The  eye  Avas  free  from  all  signs  of  irritation.  Four  months 
later  (October,  1878)  inflammatory  symptoms  suddenly  developed  in  the  left 
eye.  At  the  time  of  his  entry  (June  13.  1878),  the  lids  were  swollen,  chemotic 
and  anterior  chamber  filled  with  blood.  Pain  in  ciliary  region  T.— 2.  June  17, 
1878,  enucleation;  sagittal  diameter,  30  mm.;  equatorial,  29  mm.;  base  of  cornea, 
15  mm.  The  horizontally  dissected  eye  disclosed  a  large  anterior  chamber  filled 
with  blood,  anteriorly  bounded  by  a  very  thin,  vascularized  cornea,  posteriorly 
by  a  transversely  stretched  membrane,  which  takes  its  origin  from  the  iris  and 
Fontana's  spaces,  and  consists  of  a  thickened,  inflammatory,  vascularized  for- 
mation on  the  iris.  This  new  formed  layer  of  inflammatory  tissue  fills  the 
pupil,  and  in  this  area  is  firmly  adherent  to  the  lens.  The  posterior  surface  of 
the  iris,  its  pigment  layer,  for  a  short  distance  is  likewise  adherent  to  the  lens. 
More  peripherically  the  posterior  surface  of  the  iris  apparently  is  unchanged, 
and  a  posterior  chamber  exists.  With  the  exception  of  its  anterior  chamber, 
which  is  somewhat  fiattened,  the  lens  has  retained  its  shape.  Its  equatorial 
diameter  is  8.4  mm.;  its  polar,  4.3  mm.  The  fibres  of  the  zonula  are  well  pre- 
served, and  can  be  distinctly  seen  in  the  stained  sections.  The  ciliary  processes 
are  pressed  anteriorly,  and  are  long  and  thin.     Petit's  Canal  is  2.7  mm.  wide. 


200 

Aside  from  an  intense  cellular  infiltration,  tlie  ciliary  body  shows  no  changes. 
In  the  posterior  segment  of  the  eye  the  choroid  is  adherent  to  the  sclera. 
Equally  infiltrated:  nevertheless,  at  several  points  nodular  like  thickenings 
exist.  Aiitcridi-ly.  i>ostfrior  lo  the  orra  scrrata.  to  the  temporal  side,  osseous 
tissue  is  developing.  The  entire  atrophic  retina  is  detached,  and  near  the  pa- 
pilla shows  numerous  folds.  These  partly  cover  a  deep  excavation  of  the  pa- 
pilla, which  is  distinctly  visible  in  the  sections.  Both  the  flat  space  between 
the  choroid  and  retina,  as  w^ell  as  the  entire  vitreous  space,  Petit's  Canal  in- 
cluded, and  the  posterior  chamber,  is  filled  with  a  fluid  which  has  coagulated 
in  the  MuUer's  fluid.  This  undotibtedly  chemically  changed  fluid  in  the  eye 
lead  to  such  a  complete  imbedding  of  the  lens,  that  after  the  lens  had  been  cut 
in  four  parts  and  imbedded  in  stearin,  it  was  possible  to  make  fine  sections 
(Kuhnt  liUdwig).  The  other  half  of  the  lens  was  put  up  in  calabar  substance, 
and  then  cut  (Dr.  Pinto).  From  the  description  it  follows  that  the  lens  was 
held  fast  in  the  pupillary  area  and  its  immediate  nighborhood,  and  that  it  was 
connected  with  vascularized  tissue,  and  was  further  imbedded  on  all  sides 
by  pathological  liumor  aqueous  and  vitreous.  The  changes  in  the  lens  are 
highly  interesting,  and  fit  in  exactly  with  those  already  above  mentioned  in 
the  case  of  the  granulom  of  the  iris. 

A  capsular  cataract,  8  mm.  long  and  0.4  mm.  thick,  occupies  the  pupillary 
area.  This  shows  all  the  attributes  of  a  conglomeration  of  cells  without  the 
presence  of  intercellular  substance;  hence,  this  in  the  first  stage  of  develop- 
ment. In  the  equatorial  region  are  vesicular  cells.  The  inner  surface  of  the 
posterior  capsule  is  clothed  with  epithelium,  which  is  undergoing  hyperphasia. 
Tlie  lens  whorl  is  liut  partially  recognizable.  The  ch;inges  in  the  fibrous  portion 
of  the  lens  are  likewise  characteristic;  separated  lamellae,  between  which  are 
highly  light-reflecting  globules  of  coagulated  albuminous  fluid,  and  the  presence 
of  innumerable  vacuoles  in  the  peripheric  fibres  all  indicate  that  this  cloudiness, 
of  the  lens  has  developed  rapidly.  This  agrees  with  Dr.  Pauli's  statement. 
In  .Tune.  1877,  the  iris  trembled,  the  pupil  was  free,  and  the  lens  transparent. 
In  October  the  first  signs  of  changes  in  the  eye  were  noted,  which  lead  to  the 
formation  of  the  cataract.  As  the  immediate  cause  of  the  same,  one  must 
designate  the  local  adhesions  which  the  vascular  pseudo  membrane  in  the  pupil 
and  tlie  i)atli()l()gieal  nutritive  siii)i»ly  on  the  part  of  the  vitreous. 

CATAKACTA    CAI'SULO-LP^XTICULAHIS    COMPLICAT.V  (I)l<:TA(MniENT 
OP  THE  RETINA). 

Mrs.  K.,  .-ibont  4(»  years  of  age.  was  treated  by  Steffan,  to  whom  1  am  in- 
debted for  this  eye.     I  take  the  following  from  his  notes: 

October,  ]S7:'.,  s1ai)ly()iiia  posticum  progress.  Choroiditis  dissemin:it;i.  Cat- 
aract polaris  posterior.  Inner  half  of  field  of  vision  wanting.  Externally  she 
still  counts  fing«'rs  at  1.."..  Right  eye.  Irido-choniiditis,  .aiarMcia  ••apsularis 
accreta.  Ciliary  irritation.  Amaurosis.  This  eye  was  enucleated  October  7, 
1873.     Two  years  later,  October  7,  1895.  the  eye  was  opene<l  horizontally.     The 


20I 

retina  was  totally  detafliod,  llic  ciitlic  si>;icf  lictufcn  tiiis  ;iii<l  tlio  choroid 
was  tilled  with  cholesteariu  crysials.  Tin-  rctiiin,  lui^cihcr  witli  cyclitif  l)ands, 
encloses  completely  the  posterior  section  of  tlic  eye.  Anteriorly  it  is  covered 
by  the  irido-cyclitic  new  formations,  wliicli  also  cover  the  pupil.  As  the  result 
of  these  bands  the  iris  in  its  peripliery  is  drawn  posteriorly;  as  a  result,  the 
anterior  chamber  is  unusually  deep.  It  is  especially  worthy  of  note  that  the 
pupillary  edge  of  the  iris,  togetlier  wirli  tlic  spliiiictor.  is  drawn  backward  by 
the  cyclitic  bands.  Hence,  I  observe  licre  for  tlic  liisf  time  ji  condition  directly 
the  opposite  of  that  so  frequently  observed  in  glaucoma.  Microscopically  one 
can  see  that  the  lens  consists  of  two  distinct  parts.  The  entire  anterior  and 
posterior  capsule  is  covered  with  a  capsular  cataract.  On  fine  sections  one  can 
see  that  it  is  formed  like  all  other  capsular  cataracts.  At  some  points,  how- 
evei",  small  and  large  particles  of  amorphous,  chalky  microscopical  granules 
are  deposited.  This  always  occurs  tirst  iia  the  spaces  between  the  tissue,  and 
surround  and  gradually  displace  the  nuclei.  The  farther  inward  we  proceed 
the  larger  and  more  compact  do  these  concretions,  whicli  gradually'  assume  the 
shape  of  Drusen,  become.  Almost  the  entire  space  witliin  the  capsule  sac  not 
occupied  by  the  capsular  cataract  is  filled  with  the  chalky  deposit. 

In  this  case  entire  calcification  of  the  lens  ensued,  without  a  rupture  of  the 
capsule  having  taken  place. 

CALCIFTCATIOX  OF  THE  LENS.  Since  deposits  of  lime  salts 
within  the  capsular  sac  most  frequently  occur  under  the  above  considered 
conditions — that  is,  where  the  cataract  occurs  consecutive  to  some  previous 
disease  of  the  eye,  which  has  led  to  permanent  firm  adhesions  between  the 
lens  and  pathological  vascular  tissues — this  condition  will  be  considered 
here.    It  has  also  been  described  as  a  pel rif  cation  of  the  lens. 

Under  these  conditions,  the  deposits  of  lime  salts  always  occur  first 
iu  the  new-formed  tissue,  which  is  derived  from  the  hyperplasia  of  the 
intracapsular  cells.  Nevertheless,  a  deposit  of  lime  salts  not  infrequently 
does  occur,  but  where  the  lens  is  simply  fixed  in  its  position  by  a  simple 
synechia,  or  in  cases  where  a  youthful  individual  has  suffered  destruction 
of  the  deep-seated  structures  of  the  eye;  hence,  under  conditions  to  be  con- 
sidered presently.  Under  such  conditions,  the  deposit  of  lime  salts  is  not 
preceded  by  an  extensive  capsular  cataract.  The  deposit  of  the  amorphous 
granules  of  lime  takes  place  first  on  the  inner  surface  of  the  epithelium 
of  the  anterior  and  of  the  pseudo  epithelium  of  the  posterior  capsule,  and 
extends  gradually  from  the  periphery  to  the  centre  of  the  lens.  This  is 
demonstrated  by  the  fact  that  at  times,  the  innermost  nucleus  is  not  cal- 
careous, but  consists  of  an  amorphous,  smeary,  at  times  waxy,  mass.  This 
is  certainly  worthy  of  note,  since  one  must  assume,  that  though  this  grad- 
ual petrification  is  steadily  going  on,  from  without  inward;  that 
though  finally  there  must  be  a  verv  considerable  crust  of  lime  salts,  this 


202 

must  still  be  permeable  to  the  inorganic  constituents  of  the  nutritive  fluid. 
Minute  calcareous  deposits  are  at  times  noted  in  over-ripe,  senile,  non-com- 
plicated cataracts.  They  always  appear  as  thin  lamellae  of  highly  refracting 
granules  close  to  the  capsule,  and  at  times  they  look  like  crystals.  Neverthe- 
less, I  have  never  been  able  to  distinguish  crystals  with  certainty.  A  total  cal- 
cification always  requires  a  long  time — months,  and  even  years.  This  is 
due  to  the  slight  amount  of  organic  constituents  of  the  vitreous,  and  the 
always  sluggish  interchange  of  nutritive  fluid  in  a  diseased  eye. 

The  petrification  of  the  lens  is  either  local,  or  the  entire  lens  is  in- 
volved. The  former  condition  is  observed  in  the  over-ripe  senile  cataract, 
the  latter  in  the  consecutive  and  complicated  cataracts  of  youth.  In  chil- 
dren, the  contents  of  the  capsule  may  remain  fluid  and  gradually  become 
inspisated,  (catarada  lactea),  or  the  formation  may  be  a  solid,  strong  one 
from  the  beginning,  {catarada  calcarea)  (gypsea). 

Beer  noticed  that  when  the  eye  is  kept  perfectly  quiet  for  a  time,  a 
color  difference  develops  in  these  milky  cataracts,  in  such  a  manner  that 
the  lower  half  gets  chalky  white,  whereas  the  upper  half,  has  a  more  yellow- 
ish color.  If  one  waits  long  enough,  this  line  of  separation  mil  become  an 
almost  straight  line.  This  phenomenon  is  due  to  the  precipitation  to  the 
floor  of  the  capsular  sac  of  the  heavier  calcareous  granules.  Xaturally,  this 
difference  can  only  become  distinct  where  the  fluid  portion  is  relatively 
great.  Hence,  the  milky  cataract  does  not  always  appear  to  have  sediment, 
and  it  is  not  always  an  easy  matter  to  differentiate  between  a  catarada 
ladea  and  a  catarada  calcarea.  One  must  judge  by  the  uneven  tuberous 
surface  of  the  latter,  as  compared  with  the  perfectly  even  surface  of  the 
former.  Also,  the  more  exact  light  sense  in  cases  of  cataracta  lactea  may 
aid  us  in  making  a  correct  diagnosis. 

OSSIFICATION  OF  THE  LENS.  The  question  of  the  possibihty 
of  an  ossification  of  the  lens,  naturally  follows  upon  the  consideration  of 
catarada  calcarea.  Technically  speaking,  the  question  is.  not,  whether 
at  the  place  where  the  lens  normally  is  found,  a  deposition  of  true  bony 
substance  is  found,  but  whether  bone  can  be  found  inside  of  a  lens  capsule 
which  has  never  been  ruptured.  The  latter  proposition  is  denied  by  me 
(Becker),  the  former  is  not  contradicted.  Where  this  bony  body  simulates 
the  form  of  the  lens,  it  will  always  be  found  that  the  space  which  the  latter 
originally  occupied  is  entirely  surrounded  by  pathological  tissue,  forming  a 
perfect  mold  of  the  lens.  The  following  case  will  demonstrate  in  how  re- 
markable and  rapid  a  manner  this  can  occur:  Ward  Holdeii.'  in  a  patho- 
logical report,  confirms  these  statements: 

1  A  case  of  Ossification  of  tlie  Lens.  Clinical  History  by  Dr.  .Tolin  Dunn. 
Pathological  Rj'port  by  W.inl  Iloldcu.  Arcliives  of  Optliahnolony.  Vol.  XXVII, 
No.  5.     1898. 


203 

Case.  September  28,  1882,  a  father  accidentally  struck  his  son  in  the  right 
eye  witli  a  pitch-fork.  On  September  29,  1882,  the  conjunctiva  bulbi  was  found 
oedematous,  and  downward  and  inward  in  the  cornea  was  found  a  right-angled 
flap  wound.  Blood  in  the  anterior  chamber.  Globe  soft.  Perception  of  light 
present.  Projection  wrong.  September  30,  1882,  at  12  o'clock;  hence,  forty- 
three  hours  after  the  injury,  the  eye  was  enucleated  and  placed  in  chromic 
acid.  December  14,  1883,  the  eye  was  cut  and  imbedded.  Macroscopically  we 
believed  that  the  lens  was  applied  to  the  posterior  surface  of  the  cornea.  Under 
the  microscope  it  was  shown  that  simply  the  capsule  was  present,  but  that  the 
lens  had  been  extruded  at  the  time  of  the  accident.  The  capsule  had  filled  with 
blood,  and  thus  had  simulated  the  presence  of  the  lens.  The  vitreous  was  very 
much  infiltrated,  and  the  pars  ciliaris  retinae  was  being  changed  into  a  cyclitic 
band.  It  can  scarcely  be  doubted  but  that  this  space  which  the  lens  had  occu- 
pied, and  which  was  now  filled  with  blood,  in  course  of  time  would  have  been 
occupied  by  new-formed  tissue.  If  this  later  had  become  changed  to  bone,  we 
would  have  found  a  bony  formation  occupying  tlie  position,  and  having  the 
exact  form  of  the  lens;  but  this  certairrly  would  not  liave  indicated  that  the 
lens  had  been  changed  into  bone.ia 

PERFORATION  OF  THE  LENS  BY  A  GLIOMA  OF  THE  RETINA. 

"IwanhoCf  lb  speaks  of  this  condition,  and  makes  the  fine  distinction,  that 
contact  of  a  tumor  could  be  looked  upon  as  a  trauma.  First,  it  arouses  the 
intra-capsular  cells  to  a  hyperplasia;  after  a  length  of  time  the  new  formation 
destroys  the  capsule  by  usur;  after  this  nothing  impedes  the  entrance  of  the 
cellular  elements  of  the  new  formation  as  well  as  lymphoid  cells,  and  finally 
the  new  formation  and  its  stroma  and  vessels  within  the  capsular  sac.  until 
finally  the  entire  lens,  like  any  other  tissue,  is  entirely  destroyed. 

"My  former  assistant,  Dr.  Bettmann,  examined  such  an  eye.  in  wliich  the 
usur  of  the  capsule  undoubtedly  occurred  only  a  short  time  before  the  enucle- 
ation. The  epithelium  has  given  rise  to  the  already  so  often  spoken  of  hyper- 
phasia  of  pseudo-epithelium  and  vesicular  cells.  At  the  point  of  perforation 
somewhat  anterior  to  the  equator,  a  broad  strip  of  round  cells  is  working  its 
way  toward  the  center,  whereas  another  is  pushing  its  way  along  tlie  inner 
surface  of  the  anterior  epithelium." 

PERFOEATION  OF  THE  CAPSULE  OF  THE  LENS,  AS  THE  EE- 
SULT  OF  THE  TRACTION  OF  CYCLITIC  BANDS. 

In  this  conniectioii,  Becker  discusses  a  case  described  b}'  Haab.^  He 
concludes  that  the  cyclitic  bands,  together  with  the  vessels  they  contain, 
are  the  result  of  a  foetal  irido-choroiditis.     As  a  result  of  the  traction  of 

la  See  reference  In  Yahresbericht  fur  Opthal..  1880.  p.  367. 
lb  Beitrag  zur  Pathologischen  Anatomic  des  Hornhaut  und  Linse  Epithelels 
Pagenstecher  Klinische  Beobachtungen,  Bd.  Ill,  p.  126. 

2  Uber  Angeborene  Fehler  des  Auges.     Arch.  f.  Optli..  Bd.  XXIV.  2.  p.  274. 


204 

these  bands  on  tlie  posterior  capsiile  in  an  eye  which  had  become  ectatic, 
the  posterior  capsule  burst. 

In  his  'Tathology  and  Therapy,"  page  284,  Becker  gives  the  follow- 
ing hints  regarding  the  operative  interference  in  these  various  forms  of 
catarada  accreta:  "It  is  not  without  good  reason,  that  every  one  expresses 
fear  in  operating  cataracts  which  have  formed  adhesions.  However,  only 
those  offer  a  bad  prognosis  which  have  as  a  basis  an  extensive  traumatic 
cyclitis.  Whereas  the  presence  of  a  single  capsular  synechia  can  easily  be 
overcome  by  the  cystitome,  at  tlie  time  of  the  capsular  incision,  it  certainly 
is  very  easily  understood,  that  the  more  extensive  the  adhesions,  the 
greater  will  be  the  difficulties  encountered  in  loosening  them.  In  eases 
of  a  broad  adhesion,  it  will  be  advisable  to  make  a  preliminary  iridectomie 
before  the  cataract  operation.  Ai'lt  drew  attention  to  the  fact,  that  by  this 
means,  not  only  were  a  large  niimljer  of  adhesions  broken  up,  but  also  the 
predisposition  to  an  iritis  was  lessened.  The  danger  in  the  operations  un- 
doubtedly is  due  to  the  fact,  tluit  an  inflammatory  process  which  has  just 
about  subsided  or  is  even  yet  present  in  the  latent  form,  is  lighted  up  again. 
Whereas  the  presence  of  cyclitis  most  emphatically  contra-indicates  opera- 
tive interference,  this  is  allowable  in  simple 'iritis;  hence  this  gives  us  the 
measure,  as  to  the  course  to  be  pursued  in  cases  of  cataract  a  accreta.  Hence, 
where  there  is  the  slightest  doubt  as  to  a  cyclitis,  the  operation  can  not  be 
delayed  too  long;  the  longer  one  waits,  the  more  certain  can  one  be  that 
the  cyclitis  has  really  ceased,  and  the  less  is  its  recurrence  to  be  feared." 

CHAPTER  VIII. 

CATAKACT   DUE   TO    DISEASE   OF   OXE   EYE,   AVITHOUT   THE 
PRESENCE  OF  ABNORMAL  ADHESIONS. 

In  these  cases  the  cause  of  the  cataractous  formation  is  to  be  sought 
in  the  vascular  system  of  the  eye. 

CATARACTA   MOLLIS   EXCHORIOIDITIDK. 

In  18S0  1  (Boeker)  optMiitcd  on  n  ni:in  (G  velars  of  nso  for  catanu't.  X—Vz- 
During  liis  convalescence  lie  was  called  on  by  liis  daughter,  24  years  of  age, 
who  had  on  her  left  eye  a  posterior  cortical  cataract,  which  also  extended  into 
the  equatorial  region,  but  was  not  ripe.  I  kept  her  under  observation  till  close 
of  1881,  and  repeatedly  liad  licr  general  condition  examined  into;  also  her 
urine  (for  albumen  and  sugar),  but  this  was  always  negative.  The  cataract 
was  extracted  as  soon  as  vision  sank  to  tlie  recognition  of  the  movements  of 
the  hand.  1  wisli  to  state  lyositivcly  tliat  before  the  operation  projection  was 
perfect,  the  Held  of  vision  tree,  and  the  smallest  candle  flame  was  visible  in 


205 

the  entire  room.  The  operation  anil  time  of  liejillny  were  willioiit  mishaps; 
but  after  complete  restoration  the  patient  could  only  count  fingers,  and  then 
only  when  they  were  held  to  the  temporal  side.  A  subsequent  discissio  cata- 
ractae  secundariae  did  not  improve  her  vision.  The  cause  was  found  in  a  great 
number  of  vitreous  opacities,  and  it  was  impossible  to  tell  whether  a  detach- 
ment of  the  retina  liad  occurred. 

There  can  scarcely  be  a  doubt  but  that  during-  tlic  operation,  a  cho- 
roidal hemorrhage  had  set  in,  and  that  tliis  was  due  to  a  disease  of  the 
choroid.  Cataract  forauition  on  the  one  cyo  iindouljlcdly  was  due  to  the 
presence  of  choroidal  disease;  the  other  eye,  the  right,  was,  and  is  at  the 
present  time,  perfectly  healthy. 

Becker  reports  a  second  case,  in  which  vision  was  better  and  the  in- 
tensity of  the  disease  less.  He  concludes,  ''The  presence  of  cloudiness  of  the 
lens  does  not  depend  alone  on  the  intensity  of  the  disease,  but  probably  on 
the  length  of  time  a  less  severe  disease  or  some  special  unknown  constituent 
of  the  vitreous  is  acting. 

Knapp  1  states  that  he  believes  that  the  formation  of  senile  cataract  is 
more  fre([uently  associated  with  opacities  of  the  vitreous  than  one  would 
imagine.  In  many  cases  of  incipient  cataract  he  was  able  to  diagnose 
opacities  of  the  vitreous. 

CHAPTP]R   IX. 

CONSTITUTIONAL  CATAEACT. 

Constitutional  disease,  the  nature  of  which  is  still  unknown,  may  lead 
to  disease  of  the  choroid  and  retina,  and  this,  in  turn,  to  cataract. 

.4. 

CATARACTA   POLAEIS    POSTEKIOR   IX    RETIXITIS    PIG- 
MENTOSA. 

For  a  long  time  past,  oculists  have  recognized  a  form  of  cataract, 
which  seems  to  depend  on  choroidal  disease,  which  develops  spontaneously 
in  individuals  who  have  not  reached  advanced  age,  and  wliicli  characterizes 
itself  by  the  fact  that  it  develops  in  the  posterior  coil  leal  .-uhstance,  re- 
maining stationary  for  a  long  time,  or  relatively  early,  going  on  to  tlie  com- 
pletion of  a  total  cataract.  As  the  result  of  the  studies  relating  to  the  mode 
of  nutrition  of  the  lens,  this  assum])tion  has  been  verified. 

The  clinician  has  based  his  reasons  for  this  belief  on  the  occun-ence  of 
a  choroiditis  before  the  formation  of  this  form  of  cataraiM.  or  the  finding 


1  Bericht  uber  das  Siebentes  Ilundert  Staar  Extractioneu.    Arcli.   f.  Opth., 
Bd.  XI.  1,  p.  49. 


2o6 

of  its  results  after  a  successful  extraction.  One  often  finds  disease  of  the 
vitreous,  and  since  we  have  grounds  for  believing  that  the  disease  of  the 
vitreous  is  dependent  on  disease  of  the  choroid,  these  facts  strengthen  the 
above  argument.  Scarcely  a  clinical  fact  seenxs  to  attest  this  more,  than 
the  occurence  of  a  posterior  cortical  cataract  in  a  case  where  retinitis  pig- 
mentosa has  existed  for  a  long  time. 

At  first  there  appears  at  the  posterior  pole  a  round,  almost  button- 
like, opacity.  To  this  is  added,  at  first,  one;  later,  a  number  of  opacities 
radiating  and  running  to  a  point.  These  striations  gradually  elongate, 
until  finally  a  total  cataract  is  developed.  This  cloudiness  never  reaches 
the  greatest  degree  of  saturation,  but  always  remains  more  or  less  trans- 
parent. 

x4s  long  as  this  opacity  is  present  only  at  the  posterior  pole,  a  doubt 
might  arise  as  to  whether  we  are  dealing  with  a  deposit  from  the  vitreous  or 
with  an  opacity  in  the  lens.  But  the  appearance  of  the  radiating  striations 
at  once  tells  us,  that  the  cloudiness  is  in  the  cortical  substance  of  the  lens. 

Landolt  has  afforded  us  the  anatomical  demonstration.  Transverse 
sections  of  the  lens,  taken  from  an  eye  which  had  retinitis  pigmentosa, 
show  in  both  the  posterior  and  anterior  cortical  substance,  a  separation  of 
the  various  lamellae  without  any  true  molecular  cloudiness  of  the  lens 
fibres.  In  the  spaces  between  the  lamellae  of  the  lens  he  found  coagulated 
Morgagni's  globules.  Both  posteriorly  and  anteriorly,  he  found  a  thin 
section  nf  clear  lens  substance  adherent  to  the  capsule. 

Other  forms  of  cataract  are  seldom  added  to  the  post  polar  cataracts  of 
retinitis  pigmentosa.  Mooren  i  ouce  observed  a  ease  which  developed  into  a 
total  cataract.  Becker  examined  a  case  of  capsular  cataract,  showing  great 
folds  in  the  capsule,  the  posterior  segment  of  which  had  been  examined  twenty 
years  before  by  Czerny  on  account  of  the  pigmentation  of  the  retina.  Unfor- 
tunately the  lens  was  so  small  that  one  could  not  discern  positively  whether 
there  was  not  also  a  posterior  polar  cataract. 

B. 

CATARACTA  CHOEOIDEALIS.  CHOEOIDAL  CATARACT. 

This  form  of  cataract  is  differentiated  from  the  above  form  of  cho- 
roidal cataract  as  seen  in  retinitis  pigmentosa,  by  its  more  rapid 
progress.  In  this  form,  the  cloudiness  which  is  at  first  con- 
fined to  the  posterior  cortical  subst<ance,  relatively  speaking,  rapidly  be- 
comes changed  to  a  total  cataract.  In  this  form  we  find  that  the  nucleus, 
even  in  individuals  advanced  in  life,  becomes  cloudy  and  has  even  been 
observed  to  become  soft. 


1    Opthalminatr.  Beobachtungen.    Berlin,  18G7. 


207 

(Becker.)  In  the  fall  of  1881  a  lady,  29  years  of  age,  came  to  me  for  treat- 
ment. A'ision  had  been  good,  but  after  having  lived  through  times  of  great 
fright,  sorrow  and  trouble  during  the  war,  she  noticed  that  vision  was  failing 
in  both  eyes.  This  was  found  to  be  due  to  opacities  in  the  vitreous  and 
posterior  cortical  cataract.  I  made  a  preparatory  iridectomy  on  both  eyes,  and 
subsequently  practiced  discission.  To  my  astonishment,  after  complete  resorp- 
tion, I  found  the  vitreous  clear.  I  imagine  that  aside  from  hastening  the  ripen- 
ing of  the  cataract,  the  iridectomy  had  a  favorable  influence  on  the  choroidal 
disease,  which  was  the  cause  of  the  opacities  in  the  vitreous. 

Those  who  have  experimentally  studied  the  nutritive  processes  in  the 
lens,  have  also  turned  their  attention  to  the  relation  existing  between  poste- 
rior polar  cataract  and  the  diseases  of  the  choroid  and  retina.  (Choroiditis 
disseminata,  chorio-  retinitis,  retinitis  pigmentosa,  etc.)  Thus  Kneis^ 
and  Ulrich^.  The  latter  says,  "At  best,  even  under  normal  condi- 
ditions,  the  posterior  pole,  as  far  as  its  nourishment  is  concerned,  is  un- 
favorably situated,  and  if  we  stop  to  consider,  that  in  cases  of  so-called  cho- 
roidal cataract  those  conditions  are  found  in  which  the  fimction  of  the 
choroid,  as  the  source  of  nutrition,  has  suffered,  (chorio-retinitis  and  retini- 
tis pigmentosa),  to  use  a  short  expression,  we  might  designate  this  form  of 
cataract  as  inanition-cataract. 

C. 

TOTAL  CONGEXITAL  CATARACT. 
CATAEACTA  CONGENITA  TOTALIS  OCULI  UTRIUSQUE. 

The  total  congenital  cataracts  are  always  present  on  both  eyes.  They 
may  be  soft,  even  fluid;  of  firm  consistence,  or  shrunken,  and  are  often 
adherent  to  the  iris. 

Tp  to  the  time  of  the  publication  of  Becker's  work  on  the  anatomy 
of  the  lens,  no  cases  of  congenital  total  cataract  had  been  studied  anatom- 
ically. He  was  given  the  opportunity  of  examining  five  eyes  obtained  from 
three  children,  in  whom  cataract  existed  at  birth,  and  who  had  died  from 
intercurrent  diseases.  It  will  be  of  gTcat  practical  value  to  cite  these  cases 
in  full,  since  they  will  give  us  the  key  to  the  proper  understanding  of  a 
number  of  congenital  cataracts,  which  were  examined  after  they  were  ex- 
tracted. 

CAgE  l.-CATARACTA  CAPSULO   LENTICULARIS   CONGENITA. 
Peter  Buttmann.  of  Opan.   twenty  weeks  old,   was  brought  to  the  clinic 
July  29,  1877.    He  was  a  pale  anaemic  child,  and  was  being  raised  by  artificial 


2  Die  Ernahrung  des  Auges  und  die  Abflusswege  der  Intra-ocularen  Flussig- 
keiten.    Arch.  f.  Aug.,  Bd.  VII,  p.  340. 

3  Uber  die  Ernahrung  des  Auge  Graefe  Arch..  Bd.  XXVI,  Bd.  3.  p.  43. 


208 

feeding.  According  to  the  statements  of  tlic  parents,  at  hirtli  liis  pupils  were 
black.  At  the  end  of  two  montlis  tliey  observed  tliat  tlie  pupils  appeared 
cloudy.  From  the  fact  that  the  child  no  longer  followed  a  bright  object  with 
its  eyes,  they  concluded  that  either  the  child  did  not  see  well,  or  possibly  was 
blind.  On  examination  both  cornea,  iridis  and  anterior  chambers  were  found 
normal.  Both  pupils  were  equally  grey,  and  reacted  promptly  to  light.  Before 
an  operation  could  be  done  the  child  died  of  marasmus  on  .July  2d.  Shortly 
after  death  both  eyes  were  enucleated  and  preserved  in  MuUer's  fluid.  In  .Jan- 
uary, 1882,  the  right  eye  was  cut  in  half  horizontally.  The  retina  was  in  posi- 
tion, the  vitreous  slightly  detached.  The  lens  and  capsule  had  retained  their 
normal  shape.  The  lens  showed  a  diffuse  grey  cloudiness  close  to  the  anterior 
capsule,  and  this  was  surrounded  by  a  darker  homogenous  mass.  Both  portions 
appeared  equally  hard.  Examination  of  the  vitreous  in  the  fresh  state  disclosed 
Innumerable  round  and  proliferating  cells. 

Both  halves  were  first  imbedded  in  glycerine  mass,  then  cut  in  the  equa- 
torial region,  and  the  anterior  half  reimbedded.  and  on  .January  30th  cut  with 
the  microtome.  Whole  series  of  sections  0.01  mm.  in  thickness  were  easily 
obtained. 

The  equatorial  diameter  of  the  entire  lens  equals  7.77  mm.,  whereas  the 
equatorial  diameter  of  the  microscopically  cloudy  portion  equals  0.3  mm.  The 
length  of  the  axis  of  the  entire  lens  equals  4.5  mm.,  whereas  the  cloudy  portion 
equals  4.13  mm.  The  microscopical  examination  shows  that  the  form  of  the 
lens  is  due  to  the  uninjured  capsule.  The  thickness  of  the  latter  varies.  At 
the  anterior  pole  it  Is  0.01  mm.  in  thickness;  posterior  to  the  equator  this  in- 
creases to  0.017  mm.,  and  at  the  posterior  pole  scarcely  reaches  0.0023  mm.  The 
cloudy  portion  is  really  the  part  of  the  lens  Avhich  is  made  up  of  lens  fibres; 
the  darker  mass  which  surrounds  this  consists  of  coagulated  amorphous  fluid, 
in  which,  here  and  there,  a  loosened  lens  fibre  is  imbedded.  Anteriorly  the  lens 
is  adherent  over  an  area  of  5.0  mm.,  to  a  developing  capsular  cataract  of  more 
than  0.2  mm.  thickness.  The  epithelium  is  wanting  in  the  area  of  the  capsular 
cataract.  In  the  interspace  of  the  fibrous  capsular  cataract,  innumerable  nuclei 
are  found,  which  are  beautifully  shown  hj  double  stains  of  hacniotoxylin  .iiul 
oesin.  or  with  alum  carmin.  Close  to  tlie  capsular  cataract  the  caitsular  (('lis 
are  well  preserved.  They  are  still  cubical,  and  whereas  the  capside  shows 
thickness  of  0.01  mm.,  they  are  equally  thick  and  high.  Tlie  nuclei  show  a 
diameter  of  0.005  mm.,  and  occupy  the  center  of  tlie  cells.  Soon  the  height  of 
the  cells  increases,  and  reach  a  height  of  0.002  mm.  At  the  same  time  the 
nucleus  does  not  increase  in  size,  but  approaches  closer  to  the  upper  end.  At 
the  same  time  the  capsule  grows  thinner,  and  measures  0.007  to  0.008  mm.  In 
the  equatorial  region  the  capsular  <clls  attain  a  licighl  of  (i.o;',S  to  0.04  mm., 
whereas  the  capsule  diminishes  in  thickness  to  (t.Ool  mm.  It  is  to  lie  noted  that 
the  line  along  wliidi  tlic  cells  begin  to  apply  tlionisclvos  slanting  lies  far  pos- 
terior to  the  equator. 

Inward  from  tlie  capsular  lamellae  lies  a  nui.-h  iiioie  extended  second  layer 


209 

of  quite  rt'sularly  ;irr:in«va  opillu'lijil  cells  of  imieh  Imser  size.  These  cells 
attain  a  height  of  0.05  nun.,  and  a  width  of  from  0.02  to  0.04  mm.  The  nucleus 
has  the  same  diameter,  0.0')  mm.,  as  the  epithelial  cell.s.  These  are  situated 
along  a  line  of  the  capsule  which  only  possesses  a  tliickness  of  O.OftO  nun.,  and 
the  epithelium  a  height  of  0.025  mm. 

At  some  points  groups  of  these  epithelial  cells  lie  on  the  true  epitlielium. 
That  these  cells  are  derived  from  the  true  epithelium  appears  from  the  fact 
that  some  of  the  latter  can  be  observed  undergoing  vesicular-like  changes  (goblet 
cells).  The  formation  noted  in  all  the  sections  in  the  equatorial  region  in  all 
probability  are  produced  in  like  manner.  They  consist  of  a  tissue  which  re- 
minds one  of  a  capsular  cataract  (containing  more  cellular  elements  and  lens 
fibrous  tissue),  and  are  rich  in  coagulated  Morgagni's  fluid,  which  tills  the  inter- 
spaces. As  far  as  these  structures  extend  the  epithelium  is  wanting.  Since 
the  configuration  in  all  sections  is  the  same,  hence  :i  thick  process  extends 
posteriorly  within  the  capsule  toward  the  center  of  the  lens  into  the  coagulated 
fluid.  The  centrally  located  solid  body,  on  very  fine  meridional  .sections,  dis- 
closes beautifully  the  structure  of  the  embryonal  lens.  Lamella  after  lamella 
can  be  traced:  anteriorly  they  meet  in  a  narrow  fissure,  posteriorly  ending  in 
an  open  triangular  fissure.  The  fibres  on  both  sides  of  the  fissures  appear  to 
be  attempting  to  approach  each  other,  but  are  prevented  by  a  1  mm.  wide  solid 
nucleus,  which  consists  of  sagittal  curved  fibres.  In  this  nucleus  one  can  easily 
recognize  the  lens  fibres  of  tlie  second  period  of  foetal  development,  whereas 
the  fibres  on  either  side  of  the  fissur  belong  to  the  third  period.  Nuclei  in  the 
final  stage  of  retrogressive  metamorphosis  are  only  recognizable  in  the  outer 
lamellae.  On  transverse  and  vertical  sections  the  fibres  disclose  a  peculiar  con- 
dition, which  becomes  especially  distinct  by  the  double  stain.  The  entire  tissue 
is  permeated  by  numberless  minute  drops,  which  at  first  give  us  the  impression 
of  being  nuclei  which  have  taken  the  stain  more  deeply.  This  inequality  of 
size,  lack  of  structure,  and  their  position  between  the  fibres,  precludes  the  pos- 
sibility of  their  being  nuclei.  They  remind  one  of  globules  of  fat,  a  condition 
which  was  lately  referred  to  again  by  Henle  and  Michel  as  occurring  in  the 
embryos,  and  the  new  born  chickens,  cats,  goats,  calves  and  rabbits.  Loosened 
lens  fibres  extend  out  into  the  fluid  which  surrounds  the  body  of  the  lens,  and 
these  plainly  indicate  the  progressrve  disintegration  and  solution.  They  do  not 
show  the  well  known  fibre  endings,  liut  the  edge  appears  as  though  they  had 
been  '"gnawed  at." 

If  we  would  now  attempt  to  1'onnulate  an  o|tiiii()ii  as  to  how  tliis  con- 
dition was  broua-hi  about,  tlie  first  iliini:-  to  be  done  is  to  fix  tlie  tiiue  when 
this  disease  process  began.  The  concentric  structure  of  the  lens,  the  pres- 
ence of  the  tri-star  figure,  are  positive  indications,  that  the  fonnation  of  the 
lens  had  gone  on  uninterruptedly  with  llie  third  period  of  foetal  develop- 
ment. The  size  of  the  lens  is  but  slightly  le.ss  than  that  of  a  new-born  in- 
fant, hence  the  date  of  jlie  beginning  of  this  disease  could  not  have  been 


2IO 

far  from  the  date  of  birth.  In  fact,  there  is  no  reason  why  we  should  doubt 
the  assertion  of  the  parents,  that  the  disease  began  in  the  first  days  or  weeks 
after  birth.  I  look  upon  this  cataract  as  congenital,  and  designate  it  as 
such;  and  I  feel  Justified  in  so  doing,  since  Knies  ^  has  observed 
that  a  capsular  cataract  may  remain  perfectly  transparent  for  a  long 
time.  Though  one  must  acknowledge  the  possibility,  that  even  in  this 
case,  which  we  have  had  the  opportunity  of  examining,  that  this  disease 
only  set  in  subsequent  to  birth,  there  is  no  reason — since,  as  has  been  ob- 
served, there  was  neither  any  other  external  or  internal  disease  of  the  eye 
nor  general  disease — why  it  could  not  be  possible  for  a  perfectly  analogous 
disease  condition  to  develop  during  the  last  month  of  intra-uterine  life. 
Undoubted  cases  of  congenital  cataract  can  be  explained  by  this  method 
of  development. 

Since  the  examination  of  the  entire  eye  did  not  disclose  a  very  florid 
disease,  which  could  be  looked  upon  as  the  cause  of  the  cataract  formation, 
this  would,  on  the  other  hand,  indicate  that  the  cataract  formation  dated 
back  to  foetal  life  and  was  due  to  a  constitutional  disease,  the  traces  of 
which  could  no  longer  be  discovered. 

CASE  2.— CATARACTA  MORGAGNIANA  CONGENITAL  O  ITTRI. 
Max  Merz,  aged  seven  weeks,  died  January  10.  1883,  of  cholera  infantum, 
at  3:30  a.  m.,  and  the  post-mortem  was  held  in  the  afternoon  at  '2:30.  Both 
eyes  were  enucleated,  and  at  once  placed  in  MuUer's  fluid,  where  they  remained 
for  six  weeks.  They  were  imbedded  in  celloidin  and  cut.  At  birth  the  obser- 
vation was  made  that  the  pupils  were  not  black  but  grey.  A  few  days  before 
death  atropine  was  instilled  into  the  eyes.  The  pupils  dilated  but  slightly.  The 
cataract  had  a  milky  color,  evenly  diffused,  and  showed  no  striations.  The 
lens  had  the  same  appearance  after  enucleation.  After  the  one  eye  had  been 
prepared  so  as  to  permit  of  imbedding,  the  entire  lens  was  examined  by 
focal  illumination  and  by  transmitted  light,  using  a  Hartnack  objective  2  and 
Oc  lY.  The  periphery  of  the  lens,  which  was  not  much  redueed  in  volume. 
was  transparent,  and  along  the  equator  one  could  recognize  cellular  elements. 
Eccentrically  situated  and  apparently  fixed,  one  could  observe  in  the  trans- 
parent capsular  sac,  the  reduced  in  size  and  transparent  nucleus.  Owing  to 
the  manipulation  preparatory  to  imbedding  and  placing  in  absolute  alcohol,  the 
entire  lens  appeared  somewhat  shrunken,  so  that  on  section  tiu'  natural  form 
of  the  lens  had  suffered  somewhat.  The  microscopical  conditions  can  be  briefly- 
given.  They  are  essentially  those  of  the  previous  case;  only  that  the  capsular 
cataract  in  the  pupillary  area  is  not  so  well  developed,  and  restricted  to  a  few 
nodules.  As  a  result,  the  nucleus  is  not  adherent  anteriorly,  lies  obliquely  in 
tlie  capsular  sac,  and  is  completely  surrounded  by  a  coagulated  homogenous 
fluid.     The  nucleus  discloses  the  same  beautiful  structure.     A  layer  of  large, 


1  Cataracta  Polaris  Aiit(M-ior  und  Cataracta  Morgagniana.    Zehender's  Klin. 
Monatsblatt,  1880.  Kd.  X\  HI.  p.  isi. 


211 

tumescent  cells  lie  on  tlic  ('iiithclhini,  and  posterior  to  tiie  ecjuator  form  similar 
pictures.  WitL  these,  however,  the  formation  of  cells  does  not  cease,  but 
clothe  the  greater  part  of  the  posterior  capsule  with  epithelial  and  vesicular 
cells.  Aside  from  this  a  number  of  hyaline  excrescences  (Drusen)  are  just  be- 
ginning to  develop  in  the  anterior  capsule,  so  that  it  may  be  noted  that  these 
also  occur  in  young  individuals. 

CASE  3.— CATAKACTA  FLUIDA  CONGENITA  O  UTR. 

Lena  Schaul,  four  years  of  age,  was  brought  to  the  clinic  November  1,  1882. 
from  tlie  Mossbach  Institute  for  mentally  deficient  children.  She  was  so  in- 
animate that  she  had  to  be  fed  artificially,  since  she  would  not  swallow.  On 
November  7,  1882,  the  left  eye  was  operated  for  cataract.  Tlie  second  eye  was 
not  operated,  since  the  patient  died  May,  1882.  of  diarrhoea,  fatty  liver  and 
"Schluck  pneumonic."  The  right  eye  after  hardening  waa,  imbedded  and  cut. 
It  Mas  then  examined  with  a  Hartnack  obj.  2,  Oc.  IV,  and  was  found  but 
slightly  reduced  in  volume.  During  life  the  diagnosis  of  a  shrunken,  mem- 
branous cataract,  with  anterior  capsular  cataract,  had  been  diagnosed.  On 
dilating  the  pupil  the  observation  had  been  made,  that  in  the  middle  of  the 
anterior  capsule,  equal  to  about  a  medium-sized  pupil,  a  white  light  was  re- 
flected, whereas  in  the  peripliery  it  was  transparent.  We  believed  we  were 
dealing  with  a  form  of  cataract  presently  to  be  described,  notwithstanding  the 
fact  that  while  operating  the  left  eye  it  was  only  possible  to  extract  the  an- 
terior capsule  with  the  cellular  hyperphasia  adlierent  thereto.  This  capsule, 
hardened  in  alcohol  and  stained,  showed  a  moderate  cellular  hyperphasia  with- 
out formation  of  fibres. 

Sections  of  the  lens  sliow  very  considerable  shrinkage,  as  the  result  of 
manipulation  previous  to  and  subsequent  to  imbedding.  This  shrinking  has 
assumed  a  higher  degree  than  in  the  previous  case,  since  it  was  shown  that  the 
nucleus  of  this  cataract,' which  at  other  times  bears  the  greatest  resemblance 
to  the  previous  cases,  was  entirely  resorbed.  It  is  to  be  noted  that  aside  from 
tlie  cellular  hyperplasia,  here  also  "Drusen"  are  present:  the  whorl  along  the 
equator  can  still  be  recognized  to  a  certain  extent,  and  as  a  rule,  there  is  no 
epithelium  along  the  posterior  capsule.  Tlie  capsular  sac  is  partly  filled  with 
coagulated,  homogenous  fluid,  partly  witli  vesicular  cells. 

CASE   4.— CATAKACTA   MEMBRANACEA   COXIJEXITA. 

Louise  Flescli.  aged  twelve  months  (Fischbach),  was  taken  up  in  the  clinic 
in  March,  1880,  with  total  cataract  on  both  eyes.  There  was  slight  nystagmus 
on  both  eyes,  cornea  clear,  no  synechia:  both  pupils  reacted  rapidly  to  light. 
Both  lenses  were  moderately  cloudy,  and  reflected  a  grey  light.  The  eyes  fol- 
lowed the  light.  After  a  previous  iridectomy  discission  was  done.  Apparently 
the  capsule  was  incised,  but  no  cataractous  masses  escape.  The  child  was  sent 
home  again,  and  subsequently,  first  on  the  right  and  then  on  the  left  eye,  an 
incision  was  made  with  tlie  lance,  and  tlie  thickened  capsule  extracted  with  the 


212 


forceps,  lu  boih  eyes  portions  of  tlie  capsule  mid  tumeseeut  substance  re- 
mained beliind.  The  extracted  portions  were  preserved  in  alcoliol.  and  were 
not  imbedded  until  the  spring  of  1882.  The  thickness  (;f  the  capsule  equaled 
0.008  mm.,  the  height  of  the  epithelial  cells  a  little  more  than  0.01  mm.  In  the 
center  of  the  anterior  capsule  lies  a  thick  capsular  cataract,  whereas  the  latter 
portions  are  free  of  tlie  same.  At  tlie  border  of  the  capsular  cataract  one  can 
observe  how  a  very  thin  lamella  of  the  capsule  separates  from  the  remainder, 
and  covers  the  cataract  on  its  inner  surface.  (N.  B.-See  the  pathology  of  cap- 
sular cataract  for  the  later  and  more  correct  ideas  on  this  subject.) 

These  four  cases  undouLtedly  Jllustrate  various  stages  of  the  same  pro- 
cess. The  general  conditions  found  present  in  all  these  cases  consist  in  the 
taking  up  of  an  abnormal  quantity  of  fluid  inside  of  the  capsule  of  a  fully 
developed  lens  (foetal  period  of  growth).  This  fluid  accumulated  between 
the  lens  and  its  capsule,  which  sei)ai-ates  the  former  posteriorly  from  the 
capsule:  anteriorly  and  in  the  equal oi'ial  region,  from  the  epithelium.  In 
all  these  cases  this  condition  leads  to  a  hyperplasia  of  the  intracapsular 
cells.  In  the  ease,  Buitmann,  this  process  was  so  active  in  the  pupillary 
area,  as  to  lead  to  the  fixation  of  the  lens  proper  by  means  of  the  forming 
capsular  cataract;  in  the  case,  Merz,  a  like  condition  is  noted,  but  it  appears 
after  the  body  of  the  lens  had  been- separated  completely  from  the  epithe- 
lium, more  active  changes  had  followed.  The  lens  proper  sank  to  the  bot- 
tom of  the  capsular  sac,  hence  lies  (H-i-entric  and  is  much  reduced  in  size. 
In  the  case,  Lena  Schaub,  the  nucleus  was  completely  resorbed.  At  the 
same  time,  one  must  bear  in  mind  that  this  patient  was  four  years  of  age, 
hence  the  cataract  was  much  older  than  the  others.  In  the  fourth  case  we 
may  assume  that  the  body  of  the  lens  was  likewise  absorbed.  The  cap- 
sular cataract  was  highly  developed,  and  on  its  inner  surface  one  can  still 
observe  vesicular  cells.  Though  only  the  anterior  capsule  was  extracted, 
one  finds  recorded  in  the  history  of  the  case,  on  the  date  of  her  discharge 
from  the  hospital,  the  remark,  that  the  pupil  of  the  left  eye  is  totally  black 
and  that  it  is  impossible  to  detect  any  cataractous  remains  and  that  the 
right  eye  shows  but  slight  remains  posterior  to  the  iris. 

In  the  first  three  cases  in  which  the  lenses  were  observed  during  the 
life  of  the  patients,  they  appeared  as  vesicles  having  the  normal  form  of 
the  lens.  Though  the  lenses  appeared  somewhat  smaller  than  one  would 
expect  to  find  them  at  that  time  of  life,  they  nevertheless  did  not  present 
the  appearance  of  a  cataracla  memhranacea,  a  condition  wliicli.  t'roin  their 
ap))earance  during  life,  one  would  have  expected  to  find. 

As  to  the  aetiology.  Ihe  occurrence  on  both  eyes  favors  a  cause  present 
in  the  general  organism.  The  nature  of  this,  since  the  cause  appears  to  have 
been  active  durinti'  foetal  life,  can  not  he  stated.     But  that  nutritive  condi- 


213 

tions  sct'iii  lo  play  an  iiiiportaiil  role.  a|ipcai->  to  Ix-  attested  hy  (ho  fact, 
that  in  all  three  eases  in  which  we  examined  ihc  cataract  in  the  eye,  the 
vitreous  showed  marked  chaii-ics.  in  hoth  the  lases,  Buttmann  and  Merz, 
the  vitreous  was  permeated  hy  pr<)lifcratii.t>-  cells,  whicii  frequently  showed 
]on<;,  swollen  processes.  In  the  case  of  i.rna  Srliaiih.  the  colls  were  more 
sparsely  distributed,  but  all  showed  uuinerous  and  dilated  processes. 

Besides  this,  the  fact  is  especially  worthy  of  note,  that  in  all  these 
cases  so  far  e.vaniined.  the  eyes  showed  no  other  signs  of  an  inflammatory 
process.  In  oi-der  to  be  perfectly  certain  in  this  matter,  I  examined  the 
vitreous  of  a  large  number  of  eyes  taken  from  the  new-born  and  very 
young  children,  and  though  I  always  found  in  this  fluid  an  increased  num- 
ber of  cellular  elements,  as  compared  with  the  vitreous  of  the  adult,  in  not 
a  single  case  did  I  find  those  forms  which  justify  iis  in  stating  that  there 
is  an  inflanmiatory  irritation  of  the  vitreous.  From  this,  one  may  conclude 
that  where  the  vitreous  shows  the  evidence  of  an  active  cellular  prolifera- 
tion, by  the  presence  of  large  numbers  of  cells,  the  vitreous  fluid  is  chem- 
ically altered,  and  hence  supplies  to  the  lens  an  abnormally  constituted 
nutritive  ni'aterial. 

J! ad  the  .second  and  third  cases  coincided  entirely  with  the  first,  one 
might  form  an  idea  as  to  the  point  where  the  first  pathological  changes 
begin  in  such  a  case.  The  absence  of  epithelial  cells  along  the  posterior 
capsule  and  the  pre>eni-e  of  the  peculiar  hyperplasias  of  cells  along  the 
whorl — hence  there,  where,  under  normal  conditions,  the  nutritive  stream 
gains  entrance  to  the  lens — indicate  very  strongly  that  it  is  just  at  those 
places  where  the  initial  changes  begin,  making  it  impossible  foj-  new  fibres 
to  form,  and  prevent  the  further  surface  advanee  of  the  dividing  epithelial 
cells,  so  that  the  new-formed  cells  are  piled  up  on  top  of  each  other,  and 
finally  lead  to  the  formation  of  a  capsular  cataract.  The  difference  in  the 
ease,  Jferz,  may  be  explained  as  due  to  a  less  intense  action  along  the  whorl, 
so  that,  though  the  formation  of  new  hms  fil)res  was  ])revented.  it  was  not  so 
wdth  the  further  advancement  and  formation  of  new  epithelial  cells.  In 
the  case.  Lena  Srliauh.  since  no  perceptible  changes  were  found  along  the 
whorl,  this  explanation  could  not  be  accepted  without  furthei-  ex])lanation. 

It  appears  that  in  the  above-des<-ribed  cases,  in  which  neithei-  remains 
of  the  hyaloid  artery,  nor  the  vascular  capsule  of  the  lens,  nor  a  foetal  iritis 
are  present,  the  genesis  of  all  those  cases  of  congenital  or  total  cataract 
occurring  on  both  eyes  during  the  first  years  of  life  is  given.  This  is  true 
as  well  of  those  in  which  a  portion  of  the  lens  is  still  present  as  in  those 
which  simply  consist  of  capsule,  hyperplasia  of  ca^jsulai'  cell-  and  fluid. 
which  latter  we  have  been  in  the  hal)it  of  designating  a>  shrunken  cata- 
racts.    It   is  possible,  in  course  of  tinu'.  according  to  the  mode  of  devel- 


214 

opment,  for  shrunken  cataracts  to  form.  Nor  can  it  be  denied  that  where 
such  a  cataract  is  not  operated  and  remains  in  situ  to  very  advanced  age, 
the  fluid  in  the  capsule  may  be  absorbed,  and  then  appears  as  a  mem- 
branous cataract  (cataracta  menibranacea).  Only  diifering  from  catarada 
memhranacea,  are  those  forms  which,  on  account  of  their  similarity  to  fruits 
dried  in  the  pod,  have  been  given  the  name,  cataracta  arida  siliquata,  by 
Adam  Schmidt.  Sucli  a  cataract,  including  its  capsule,  seems  to  have  a 
thickness  of  2  to  3  mm.,  is  a  perfectly  opaque,  yellowish  white,  caky  mass, 
and  appears  to  be  composed  principally  of  dried-up  lens  substance.  Fre- 
quently one  obsei-ves,  associated  with  such  a  cataract,  a  more  or  less  ex- 
tensive tearing  of  the  zonula  zinii,  and  then  it  trembles  with  every  move- 
ment of  the  eye;  and  it  is  then  called  a  tremWing  or  floating  cataract. 
{Cataracta  tremula  vel  natatilis).  Arlt  drew  attention  to  the  fact  that  such 
"^dried-pod"  cataracts,  as  well  as  the  membranous,  seem  to  adhere  to  one  or 
more  places  in  the  periphery,  and  hence,  where  repeated  attempts  are  made 
to  depress  them  into  the  vitreous,  they  always  seem  to  rise  up  again. 
(Cataracta  elastica).  This,  however,  can  be  partially  explained  by  the  fact, 
that  both  of  the  forms,  owing  to  their  being  so  dry,  are  specifically  lighter 
than  the  vitreo^us.  Here  at  least  the  suggestion  of  Pauli  may  be  adopted,  to 
perform  reclination  upward.  ~Wliere  the  contents  of  the  cataracta  tremula 
or  natatilis  is  fluid,  this  cataract  will  assume  the  shape  of  an  almost  globu- 
lar relaxed  bladder  (cataracta  cystica).  This  capsule  filled  with  fluid  ap- 
pears always  to  seek  its  equilibrium.  In  his  ''Pathology  and  Therapie," 
page  249,  Becker  describes  the  following  interesting  case: 

In  1874  I  extracted  from  the  eyes  of  a  woman,  36  years  of  age,  two  con- 
genital, shrunken,  membranous  cataracts,  which  w'ere  not  adherent  to  the  iris. 
Her  statement  that  these  cataracts  had  existed  since  birth  was  worthy  of  be- 
lief, since  she  also  had  nystagmus.  The  question  as  to  whether  both  these  cat- 
aracts were  shrunken,  or  whether  they  were  soft  cataracts  which  had  subse- 
quently during  extra-uterine  life  become  membranous,  may  be  set  aside.  Both 
cataracts  answered  the  above  anatomical  description  exquisitely.  Especially 
well  shown  were  the  cellular  elements  in  the  fibrous  tissue.  I  do  not  doubt  but 
that  the  entire  cataract  took  its  origin  from  the  capsule  cells.  Dr.  Raab  made 
the  examinatio.  (N.  B.— This  same  case  is  cited  in  Becker's  Anatoniie,  p.  40, 
Figure  22,  as  "Cataracta  Capsularis  Congenita." 

The  operation  was  done  as  follows:  First  an  iridectomy  was  made:  the  cat- 
aracta membranacea  was  then  grasped  by  forcing  one  branch  of  the  forceps 
through  the  zonula,  so  tliat  it  passed  behind  the  cataract  and  into  ilic  vitreous, 
and  then  by  slow  and  steady  traction  the  cataract  was  gradually  extracted. 
After  an  interval  of  several  months,  when  the  patient  again  presented  herself, 
a  most  peculiar  condition  Avas  present.  After  dilating  the  pupil  the  zonula  of 
zinii  came  into  view.     Tliis  had  remained  in  i)ositi<)n.  liad  a   faint  grey  color. 


215 

and  presented  the  appearance  of  a  striated  till  for  tli.-  uvrk.  Tliis  liad  a  per- 
fectly circular  central  hole  about  the  size  of  a  moderately  dilated  pupil,  and  on 
moving  the  eye  no  motion  of  its  own  could  be  detected.  Consequently  the 
zonula  had  not  retracted.  That  this  was  so  plainly  visible  is  no  doubt  due  to 
a  pathological  thickening  which  took  place  at  the  time  the  shrinking  process 
of  the  cataract  was  going  on. 

Finally,  the  cases  Buttmann  and  Mrrz  offer  an  explanation  for  a  large  num- 
ber of  clinical  observations,  which  formerly  were  designated  as  Cataracta  Mor- 
gagnUina  in  Children.  Both  Janin  and  Arlt  have  reported  cases  in  which  they 
have  operated  for  cataract,  where  on  opening  the  capsule  a  cloudy,  milky  or 
blueish  fluid  escaped,  a  transparent  nucleus  remaining  behind,  which  later  on 
became  cloudy.  A  cataract,  as  observed  in  the  case  Merz,  might  take  such  a 
course,  if  one  will  assume  that  the  nucleus,  as  far  as  this  still  exists,  permits 
to  a  degree  the  transmission  of  light. 

CONGENITAL  HAED  NUCLEAR  CATARACT.  Graefe's  Cases,  1 
to  3,  have  awakened  another  train  of  thought  which  I  would  fain  express 
here.  In  the  year  1879,  Alfred  Graefe  drew  attention  to  a  form  of  congen- 
ital cataract  which  up  to  this  time  had  seldom  heen  recognized/  but  which 
previously  had  heen  recognized  by  Mooren.^  This  form  was  characterized 
by  its  excessively  hard,  wax-like  consistency.  This  form  always  occurs  on 
both  eyes  as  a  total  cataract,  and  the  volume  is  always  equal  to  that  of  the 
physiological  lens.  The  cloudiness  is  more  homogenous,  or  possibly  in- 
creases, toward  the  centre.  It  is  a  greyish  white,  or  perfectly  grey  in  color. 
It  has  no  tendency  to  shrink  or  to  complications.  Capsular  cataracts  do 
not  occur.  Since  discissions  are  of  no  avail,  extraction  must  be  done.  Just  * 
corroborates  these  ataitements,  and  reports  seven  extractions  done  on  four 
children,  all  between  the  seventh  and  the  fifteenth  month.  In  all  these 
cases,  according  to  the  statements  of  the  parents,  the  cloudiness  in  the  lens 
did  not  develop  until  after  birth.  ,  In  two  of  the  cases  the  thickened  capsule 
was  subsequently  removed  with  the  forceps.  Just's  cases  differ  from  Von 
Graefe's  insomuch  that  the  former  reports  the  presence  of  capsular  cataract. 

•Just  was  kind  enough  to  send  me  four  of  the  cataracts  and  the  two  capsules 
for  microscopical  investigation.  The  latter  showed  capsular  cataracts,  without 
the  presence  of  much  intercellular  substance.  Unfortunately  the  nuclei  were 
too  friable  to  permit  of  making  of  tine  sections.  In  teased  specimens  no  ab- 
normal formation  of  the  lens  could  be  detected.  Hence,  the  examinations  gave 
but  a  negative  result. 

These  Graefe-Just  congenital  nuclear  cataracts  can  scarcely  be  looked 

4  Uber  Congenitalen  harten  Kernstaar  Sitzungs  Bericht  der  Heidelborger 
Congress,  1879,  p.  25. 

5  Opthalraiatr.  Beobaehtungen,  Berlin,  p.  209.    1807. 

6  Kernstaare  im  Kindesalter.    Ceutralblatt  fur  Aug.,  .January.  1880. 


2l6 

upon  as  anything  otlior  llian  cataraols  agreeing-  with  the  type,  Buttmann. 
If  one  will  assume  that  a  lens  which  has  become  adherent  to  the  anterior 
capsule  by  means  of  a  capsular  calaract,  is  not  reabsorbed,  but  persists  and 
becomes  saturated  with  a  fluid  wliich  coagulates  easily,  one  can  easily  un- 
derstand how  this  will  become  changed  in  a  more  homogenous  waxy  mass, 
and  then  we  have  before  us  the  congenital  hard  nuclear  cataract.  If,  on  the 
other  hand,  the  nucleus  is  not  fixed,  one  can  further  assume,  as  in  cases, 
Merz,  Scliauh  and  Flesch,  that  this  will  gradually  be  dissolved  and  re- 
sorbed.  T'hus.  in  congenital  total  cataract,  we  would  have  a  two-fold  final 
stage,  one  corresponding  to  the  cataracta  huperniatnra  reducta,  and  the 
other  to  the  cataracta  Morgagnian  a. 

CATARACTS  OF  SI'DDEN  DEVELOPMENT. 

In  one  of  Just's  cases,  the  mother  saw  the  cataract  develop  during  the 
time  the  child  had  a  convulsion.  He  cites  another  case,  according  to  which 
the  mother  likewise  s<iw  the  cataract  develop  in  the  course  of  a  few  minutes. 
The  child  (lier  sixth)  was  eight  weeks  old:  two  other  children  in  the  same 
family  had  congenital  cataract.  Just,  who  had  jireviously  examined  the 
child,  and  found  the  eyes  healthy,  saw  the  case  two  hours  after  the  occur- 
rence, and  found  a  ripe  cataract  on  the  left.  Such  occurrence  may  like- 
wise be  explained  by  our  anatomical  examinations,  if  one  will  imagine  that 
just  at  the  moment  the  mother  observed  the  cloudiness,  the  nucleus  of  the 
lens  changed  its  position  in  the  cai)sule. 

TOTAL  AC(|riRED  CATARACT  (OX  BOTH  EYES). 

D. 

CATAIIACTA    MOLLU    JX^VEXl\M.      (CATAHACTA  DLM'.ETICA.) 

As  the  result  of  direct  observation,  we  know  as  yet  but  little  of  the 
changes  which  the  elements  of  the  human  lens  undergo  during  the  forma- 
tion of  a  soft  total  cataract.  Those  authors  who  have  attemi)ted  to  experi- 
mentally produce  cloudiness  of  the  lens,  either  as  ihe  result  of  tlu'  with- 
drawal of  water,  or  of  the  action  of  intense  cold,  report  the  formation  of 
va.scuoles  in  the  epillielinui  and  in  ihe  lens  lil)res.  hi  l)otli  of  the  spon- 
taneously developed  soft  human  catarat'ts  which  I  have  been  enabled  to 
exauiiiu*  in  their  normal  ])osition  in  the  eye.  I  was  enabled  to  find  these 
vacuole-  in  and  hetwccii   the  libi-es.  l)Ul   not   in  ihe  epithelial  cells. 

I'.e.-ides  tlie  case  (if  I'apidly  developing  soft  cataract  siibsecpient  to  a 
detaohment  of  the  retina,  in  a  woman  loHy  years  of  age.  (rei)orted  on  page 
200).  1  (I'.eckcr)  have  had  the  opportniiity  of  examining  oiu'  other  soft, 
tumescent    cataract,   in    ;i    nineteen    veai-  old    diahetic    patient.      Siiu-e.  aside 


217 

from  lliis.  the  dialti'tic  ciljii-acl  is  llic  \cr\  |tiira(li;iiii:i.  |iai-  cMcllciice,  of 
;:  coustituiioiial  calaract.  il  will  he  ciiiiiiciil  ly  iJi-opcr  lo  (icscrilM'  ihis  form 
more,  fully.  And  an  nnir>!  rictcd  chiciilal  ion  of  lln-  \arion>  controversies 
existing  ooncerninL;'  the  .izcncsis  of  dialx'tic-  catai-acl  will  aid  us  in  I'orinnlat- 
ing  an  opinion  as  to  the  maniuT  in  wliieh  conslii  utional  calai-act  dcNclops. 

Case.  R.  W.,  19  years  of  age.  from  H..  a  blonde,  poorly  nourished  jrlrl.  with 
a  dry  skin,  suffered  from  diabetes.  Two  days  after  an  extraetion  had  been 
done  on  the  left  eye,  and  a  preliminary  irideetomy  on  the  right,  she  died  of 
diabetic  coma.  The  eye,  which  was  removed  twenty-three  hours  after  death, 
remained  in  MuUer's  fluid  seven  years  before  it  was  examined.  {PMgvu-es  24,  25, 
26  and  Plates  V  and  VI  were  made  from  the  sections.)  The  corneal  epithelium 
was  plainly  preserved,  notwithstanding  the  long  time  the  specimen  had  been 
in  Muller's  fluid,  and  showed  perfectly  distinctlj'  the  nuclei  under- 
going division.  The  epithelium  had  begun  to  grow  down  into  the  iridectomy 
wound.  The  stump  of  the  iris,  as  well  as  the  posterior  surface  of  the  same, 
.show  an  enormous  tumescence  of  the  pigment  cells.  These  are  so  large  that 
one  can  easily  see  the  nuclei,  a  thing  whicli  under  normal  conditions  is  very 
difficult.  Lilvewise  the  portion  of  the  iris  on  which  the  pigment  rests  is  oede- 
matously  swollen.  Around  the  periphery  of  the  iris  there  is  a  pigment  ring, 
which  is  raised  to  an  almost  veritable  swelling,  as  the  result  of  an  infiltration 
with  an  amorphous  fluid.  There  must  have  been  pathological  changes  in  the 
posterior  segment  of  the  eye  previous  to  the  operation,  for  immediately  behind 
the  lens  traces  of  blood  can  be  found  in  the  vitreous.  I  have  not  been  able  to 
decide  from  which  vessels  this  has  come. 

We  are,  liowever,  interested  more  espetially  in  tlie  conditions  of  tlie  lens. 
This  has  an  equatorial  diameter  of  8-2  mm.  and  a  sagittal  of  4-8  mm.  This 
almost  globular  form  is  due  to  the  excessive  taking  up  of  water  inside  the  cap- 
sule, Avhicli  is  partly  situated  between  the  lamellae  and  lens  fibres,  and  partly 
in  larger  (luantity  between  the  lens  proper  and  its  anterior  and  posterior  cap- 
side.  Anteriorly  this  layer  equals  0.53  mm.  in  thickness,  posteriorly,  0.0.")  mm. 
Only  along  the  equator  do  we  find  the  nuclear  zone  and  whorl  still  in  contact 
with  the  capsule.  This  fluid,  which  has  been  taken  up  in  the  capsule,  is  firmly 
coagulated:  hence,  has  not  fallen  out  of  the  finer  sections.  At  the  anterior  pole 
the  capsule  has  a  thickness  of  O.Oltt  nun.,  at  tlie  posterior.  0.008  mm.  If  one 
examine  carefully  with  a  high  power  the  epithelium  of  the  anterior  capsule, 
one  will  find  it  undergoing  a  hyperplasia  at  the  ant(>ri(>r  i)ole.  As  yet.  neither 
pearls  nor  large  accumulations  of  cells  iiave  formed,  ttut  at  numerous  points 
several  layers  of  cells  can  be  found.  Iniernal  to  tlie  I.iyer  of  cells  is  a  regular 
layer  of  albuminous  globules.  Towai'd  the  e(|uator  the  etiithelium  is  beauti- 
fully and  regularly  arranged,  and  the  whorl  is  of  extraordinary  beauty.  A  num- 
ber of  sections  show,  immediately  posterior  to  the  whorl,  an  extensive  forma- 
tion of  large  vesicular  cells.  Toward  the  center  of  the  lens  the  fibres  and  la- 
mellae of  the  lens  .-ire  separaled  fioni  each  other,  and  as  a  result  large  spaces 


2l8 

have  formed,  which  are  filled  with  coagulated  fluid.  This  has  a  tendency  to 
form  globules  similar  to  the  tissue  fluid  of  the  lens.  Whereas  the  normal  width 
of  the  lens  fibres  equaled  0.010  mm.,  the  smallest  diameter  found  equaled 
0.019  mm.  Only  in  the  peripheric  fibres  did  I  find  any  signs  of  deterioration, 
disintegration  of  the  lens  fibres,  formation  of  vacuoles,  or  punctate  cloudy 
spots. 

The  reaction  of  the  various  stains  on  the  lens  was  especially  interesting. 
Alum  carmin.  which  otherwise  is  exceedingly  good  for  staining  nuclei,  stains 
the  entire  specimen  equally,  but  does  not  show  the  nuclei  with  any  prominence. 
Likewise  haemotoxylin.  But  beautiful  and  useful  specimens  are  derived  by  the 
use  of  double  stain  haemotoxylin  eosin.  But  even  in  these  the  nuclei  at  times 
hardly  take  up  sufficient  stain  to  make  useful  specimens.  This  is  very  re- 
markable, since  only  here  and  there  over  the  entire  capsule,  certain  nuclei  take 
the  stain  more  intensely  and  appear  larger.  The  number  of  these  darkly  stained 
nuclei  increase  toward  the  equator.  At  the  whorl,  however,  all  are  pale,  show- 
ing the  various  stages  of  degeneration  to  veritable  death  of  the  nuclei.  As  a 
result  of  this  double  stain,  we  discern  delicate  chemical  differences,  which 
would  not  otherwise  have  been  discovered.  Thus  we  find  in  all  peripheral  sec- 
tions, which  have  not  been  extensively  fissured,  dark  blue  dots  and  spots,  which 
have  a  great  resemblance  to  the  fat  drops  observed  in  youthful  lenses.  Like- 
wise, the  spindle-shaped  bodies  or  interspaces  appear  blue.  But  it  must  as  yet 
remain  undecided  whether  or  not  this  is  the  result  of  sugar  contained  in  the 
tissues,  or  whether  this  is  simply  the  result  of  the  action  of  the  hardening  ma- 
terial. 

But  in  applying  the  results  of  the  anatomical  examination  to  tlie  clinical 
observations  made  on  the  living  eye,  one  must  not  forget  that  this  was  a 
cadaverous  eye,  which  had  been  preserved  seven  years  in  MuUer's  fluid.  The 
girl  died  January  11.  1874,  at  1:45  p.  m..  and  t  he  post-mortem  examination  was 
made  the  following  day  at  12  o'clock.  Notwithstanding  the  low  temperature 
during  the  month  of  January,  sufficient  time  has  elapsed  to  allow  the  forma- 
tion of  Morgagni's  globules  on  the  inner  surface  of  the  epithelium:  nevertheless, 
the  time  was  certainly  too  short  to  permit  of  so  large  an  amount  of  water  being 
taken  up  in  the  capsule.  Nevertheless,  hundreds  of  specimens  which  have  been 
preserved  in  like  manner  do  not  show  such  a  condition.  Hence,  we  may  assume 
that  the  hydropsia  occurred  during  life. 

Cssowidzki "'  collected  all  the  historical  notes  relating  to  the  occurrence 
of  grey  cataract  in  patients  suffering  with  diabetes  mellitus.  From  the 
more  recent  literature,  I  will  only  quote  that  which  seems  to  be  most  im- 
portant. 

1.  Eeports  vary  greatly  concerning  the  frequency  of  cataract  in  dia- 


7  Uber  die  bei  der  Zuckerrulu-  Vurkommenden   Augenkrankheiten.    Berlin, 


219 

betic  patients.  Fauc()iinc;iii-I)iiric>iic '  loiind  tliciii  in  O.r;  per  cent..  J. 
Mayer  ^  in  3  per  cent.,  Seegen  ^"^  in  4  \)vr  cent.;  whereas.  Von  Graefe  esti- 
mated its  occurrence  in  as  high  as  25  per  cent,  of  cases.^^  In  14|  years,  I 
(Becker)  have  treated  (50,000  eye  i)atients,  and  among  these  I  found  twelve 
cataracts  in  six  diabetic  patients;  on  five  of  these  patients  I  made  seven  ex- 
tractions during  this  time.  Hirschberg  ^-  claims  to  operate  six  to  eight 
diabetic  cataracts  yearly,  and  among  the  last  150  cataract  patients  consult- 
ing him  in  private  practice,  six  had  diabetes. 

2.  The  diabetic  gi'ey  cataract  may  occur  at  any  period  of  life;  it  is 
stated,  however,  to  occur  most  frequently  in  youth.  The  youngest  patient 
with  cataract  reported  is  a  girl  twelve  years  of  age.  (Seegen,  No.  23).  My 
(Becker's)  patients  were,  respectively,  19,  27,  38,  40,  62,  and  63  years  of  age, 
whereas  I  recollect  that  formerly  I  operated  a  number  between  the  ages 
of  18  and  35,  and  some  of  these  were  blood  relations.  Seegen's  six  diabetic 
cataract  patients  were,  respectively,  12,  39,  47,  53,  56,  and  64  years  of  age. 

3.  More  women  seem  affected  than  men.  Among  Seegen's  cases,  four 
were  women,  two  men.     In  my  cases,  the  number  was  equal. 

4.  In  diabetes  more  frequently  than  in  other  conditions,  the  cataract 
develops  simultaneously  in  both  eyes,  or  only  a  very  short  interval  inter- 
venes before  its  development  on  the  second  eye.  Seegen's  twelve  year  old 
girl  is  said  to  have  had  cataract  only  on  her  left  eye,  but  it  appears  that 
she  remained  under  observation  but  a  short  time. 

5.  Usually  one  finds  large  quantities  of  sugar  in  the  urine,  and  the 
general  condition  of  the  body  very  much  reduced.  The  cases  in  which  this 
is  not  found  to  hold  true,  is  in  older  people;  Seegen,  53;  Foerster,  52;  my 
own  cases,  62  and  63  years. 

6.  The  form  of  cataract  which  develops  in  a  diabetic  patient,  as  a 
rule,  depends  on  the  age  of  the  patient  at  the  time  of  its  development. 

In  his  "Pathology  and  Therapie,"  page  270,  Becker  states,  "Since  the 
causative  disease  is  not  limited  to  any  particular  period  of  life,  hence  the 
cataract  may  develop  in  different  varieties;  in  young  individuals  as  a  total 
soft  cataract,  in  the  aged  as  a  mixed  cataract.     Hence,  from  its  general 

8  Leber.  Uber  die  Erkraiikungon  des  Auges  lw\  Diabetes  Mellitus.  Arch, 
f.  Opth.,  Bd.  XXI,  3. 

9  Uber  die  Wirlvsamkeit  vou  Karlsbad,  Diabetes  Mellitus.  Berlin  Klin. 
Woehea.,  1879. 

10  Der  Diabetes  Mellitus.    Leipsig,  1870. 

11  Foerster-Beziehungen  der  Algemein-I^'iden  und  Organ  Erkrankungen  zu 
Verandenmgen  unf  Krankheiten  des  Sehorgans  Graefe  Saemisch,  Bd.  VII.  Cap. 
XIII,  p.  219. 

12  Uber  Staar  Operationen  und  Diabetisch  C.  Deutsch.  Med.  Wocheuschrift, 
No.  37.  1889. 


220 


appearanet'.  one  is  not  ciiahltMl  to  make  the  diagnosis  of  diabetic  cataract. 
One  does,  however,  frequently  observe  tendency  to  a  rapid  retrogressive 
metamorphosis."  ]-\)erster  states,  "that  in  the  great  majority  of  eases  in 
old  people,  the  cataract  develops  just  as  it  would  in  the  senile  form.  There 
are,  however,  cases  in  which  the  cataract  develops  in  an  entirely  different 
manner.  This  foi-m  of  diabetic  cataract  may  be  recognized,  and  has  some- 
thing peculiar  in  its  formation.  First,  the  cortical  lamellae  immediately 
beneath  the  capsule  become  cloudy:  a  thin,  bluish  grey  film  permeates  the 
entire  anterior  surface  of  the  lens,  and  its  position  immediately  behind  the 
edge  of  the  pupil  demonstrates  that  the  most  external  layers  of  the  cortex 
are  involved.  Its  color,  so  far  as  it  is  confined  to  the  sections  of  the  super- 
ficial lamellae,  is  homogenous.  Whereas  in  other  cases  this  facetting  of  the 
sectors  of  the  superficial  layers  of  the  lens  is  one  of  the  last  acts  in  the 
formation  of  cataract,  it  is  here  noted  as  one  of  the  first.  The  nucleus  and 
the  deep  lamellae  are  not  entirely  transparent,  as  can  be  seen  by  focal 
illumination.  In  the  course  of  a  few  weeks,  the  deep  layers  are  involved, 
and  finally  a  bluish,  soft,  non-nuclear  cataract  results,  which  can  not  be 
difl'erentiated  from  the  cataracta  of  youthful  individuals.  This  always 
occurs  simultaneously  on  both  eyes.  I  have  only  observed  this  form  in 
young  individuals  up  to  the  twentieth  year,  and  at  the  very  beginning  the 
appearance  of  the  lens  is  so  characteristic,  that  from  this  alone  on  several 
occasions  I  have  predicted  sugar  in  the  urine. 

As  my  (Becker's)  observations  do  not  agree  with  the  above  description, 
and  as  we  shall  see  that  other  authors  likewise  lay  great  stress  on  the  appear- 
ance of  the  cataract,  I  will  give  the  description  of  all  my  cases. 

Case  No.  1.  R.  W.,  of  H.,  aged  9  years,  was  the  youngest  individual.  The 
cataract  on  the  left  eye  was  extracted  January  8.  1874.  and  had  the  appearance 
of  a  lens  w^hich  had  become  cloudy  very  rapidly,  was  a  tumescent,  bluish  white 
soft  cataract.  Tlie  iris  shadow  was  very  pronounced.  Examination  for  sugar 
was  not  made.  On  December  4.  1873,  the  right  eye  was  noted  as  cataracta  cor- 
ticalis  posterior.  At  the  time  of  the  extraction  of  the  tirst  the  second  had  ma- 
terially increased;  nevertheless,  she  still  counted  fingers  at  5-6  feet. 

Case  No.  2.  A.  S.,  a  farmer  from  W.,  aged  27  years,  has  had  diabetes  for 
a  long  time.  At  times  8^4  per  cent,  sugar  in  llie  urine.  In  1882  he  noticed  that 
the  siglit  of  the  right  eye  was  f;iiling.  .-inil  on  Dcfcmlx'i'  ir.tli  he  eonld  only 
recognize  tin-  movements  of  llie  lumd.  rro.jeetion  good.  '[Iw  cMtarjiet  had  a 
mother  of  pearl  appearance,  tumeseeni.  .md  the  lens  star  is  darker  and  seems 
to  stand  out  from  the  cloudy  tibres.  The  iris  shadow  is  well  marked.  The  left 
eye  has  .-i,  M.  :'..  \-.  e(in:ils  .*=,  T.ens  is  cle.-ir.  M;ircli  1'Mh.  three  months  later, 
the  patient  \v;is  ex.-niiined  again.  On  tlie  right  eye  the  cntjifnct  was  somew'hat 
.shrunken,  .\titefiof  eii.-i tuber  (h-ej).  Iris  siiadow  ni.-irked.  'i'iie  dark  grey  lens 
could  otily  l)e  dete.'ted  hy  ol)ii(Hie  illiiiniii:!  lioti.     'I'lie  snbstMiiee  of  tile  lens  shows 


221 

tin«'  nidiatiiif;  striations.  Ht'tw.'cii  ilicsr  sirialioiis  arc  wliiic  piiiK'talc  duts. 
Vision  is  not  materially  altetvd.  I-ft't  cyr.  ilic  anterior  eliainlK-r  is  of  normal 
deptli.  In  the  pupillary  plane  on  focal  illimiination  one  notes  a  veil  like  hlueish- 
irrey  cloudiness,  as  though  the  lens  had  been  breathed  on.  The  lens  star  shows 
a  somewhat  more  saturated  greyish  white  color.  TIh"  nucleus  is  transparent. 
On  dilating  the  pupil  with  atropine.  Hud  tlial  the  e(iu:ii()rini  /(inc  ot  tin-  It'US 
is  cloudy  in  a  broad  zone.     Vision  reduced  to  ..\. 

Case  No.  3.  A.  E.,  a  farmer,  38  years  of  age.  came  under  olis.-rv.itioii  Maich 
0,  1S73.  The  left  lens  showed  signs  of  an  immature  soft  (•.ilar.icl.  Tiic  an- 
terior corticiilis  was  still  soft.  Counts  lingers  at  4-5  feet.  Right  lens.  Cataracta 
incipiens  II  2  \=,i,;  urine.  S.  C.  Itt42.  .Noveinber  27.  IST:;,  could  only  recog- 
nize movements  of  the  hand.  S.  (J..  lo:',:'>.  Tlie  lens  w;is  extracted  November 
28th.  Owing  to  a  slight  iritis  during  the  process  of  liealing,  a  preliminary  iri- 
dectomie  was  made  on  the  left  eye  January  .5.  1874.  and  February  27,  1874.  the 
extraction  followed.  Discharged  with  O.  1  >.  V.=?.  O.  S.  \.^j\,.  Kuhne. 
who  examined  both  lenses  for  the  presence  of  su.gar.  found  the  same  i)resent. 
(Pathologie  uud  Therapie  des  Linsen  System,  p.  271.) 

Case  No.  4.  J.  S.,  a  day  laborer,  40  years  of  age.  Sight  began  to  fail  in 
1880.  Since  December  can  only  count  lingers.  Was  taken  up  at  the  clinic  March 
7,  1881,  at  which  time  he  could  only  recognize  movements  of  the  hand.  Lens  is 
completely  cloudy;  exceedingly  tumescent.  Anterior  chamber  shallow.  Urine 
acid.  S.  G.  1030.  Quantity  passed  in  twenty-four  hours  equaled  t!72(t  cm.; 
contains  6.7  per  cent,  sugar,  equal  to  about  450.2  grms.  Extraction  was  made 
on  the  right  eye  March  9th;  left  eye  March  29th.  Healing  perfectly.  N'ision 
equalled  to  ^  The  daily  amount  of  sugar  varied.  On  tlie  day  of  his  arrival, 
owing  to  the  journey  and  poor  noiu-ishnient,  tlie  (luantity  of  sugar  was  450.2 
grms..  whereas  the  usual  quantity  was  from  200  to  300  grms.  On  the  day  be- 
fore the  first  operation,  failed  to  estimate  the  amount  of  sugar.  The  amount 
of  urine  passed  was  2780  and  1080  ccm.  In  the  next  few  days  the  quantity 
of  sugar  fell  to  80.98  and  86  grms.,  but  rose  again  during  the  following  ninety 
days  to  161.3  grms.;  sank  once  more,  but  rose  again  during  the  last  few  days 
before  the  second  operation  to  173.3  grms.  After  this  there  was  again  a  de- 
•  crease.  These  results  are  interesting  because  they  indicate  the  influence  of 
diet  during  his  trip  and  the  first  few  days  after  the  operation,  and  in  the  days 
previous  to  the  second  extraction,  during  which  time  the  patient  was  given  a 
mixed  diet,  in  order  to  strengthen  him.  In  both  cataracts  sugar  was  found. 
(See  pagt'  (;7  of  text.) 

Case  No.  5.  ^Irs.  B..  of  W..  aged  62  years,  for  the  past  three  years  has 
suffered  from  a  very  intense  degree  of  diabetes,  with  never  more  than  0.9  per 
cent,  sugar  in  the  urine.  She  has  repeatdly  been  to  Carlsbad.  For  a  year  past 
has  noted  the  decrease  of  vision  in  both  eyes.  Was  seen  for  the  first  time 
November,  1882.  O.  D.  cataracta  incipiens:  O.  S.  cataracta  nondum  matura.  In 
both  eyes  found  the  posterior  cortical  substance  and  the  equatorial  zone  very 
cloudy,  and  the  nucleus  highly  refracting  the  light.  Riglit  «>ye  counts  fingers  at 
2.3  m.;  left  eve  at  1  m.     In  1S83  tlie  c-itaract  on  tlie  left   eye  liad  advanced  so 


222 

far  that  the  radii  could  be  seen  when  the  pupil  was  dilated.  Extraction  was 
done  under  narcosis  March  7th.  Process  of  healing  uneventful.  During  the 
operation  the  aqueous  was  aspirated  with  a  pipette  from  the  conjunctival  sac, 
and  together  witli  the  lens  was  examined  by  Kuhne  and  found  to  be  free 
from  sugar. 

The  amount  of  urine  passed,  the  specific  weight  and  the  amount  of  sugar, 
especially  the  latter,  during  these  days,  though  slight  was  at  no  time  very 
great.  March  7th,  amount  of  urine  =1110;  S.  G.=-1020;  sugar -0.22  per  cent. 
March  8th,  1860,  1018.  and  0.3  per  cent.  March  9th,  1250,  1013,  0.1.  From  this 
time  on  the  urine  was  free  from  sugar  (March  15th),  only  on  March  17th.  22 
per  cent,  did  the  urine  show  signs  of  sugar. 

Case  No.  6.  Mrs.  J.  D.,  of  Z.,  a  wealthy  woman  63  years  of  age,  was  oper- 
ated on  by  me  November  16,  1871.  According  to  appearances  this  was  a  cata- 
ract senilis  simplex.  Left  eye  shows  a  cataract  incipiens.  This  lady  has  had 
diabetes  for  a  number  of  years.  Quantity  of  sugar  not  estimated.  V.  =j^. 
Opthalmoscope  revealed  a  retinitis  diabetica.  Kuhne.  who  examined  the  lens, 
found  no  sugar.     (P.  and  Th.,  p.  271.) 

Jany  ^^  gives  lis  a  very  accurate  description,  in  which  he  especially 
emphasises  the  fissiiring  of  the  cortical  substance,  which  gives  it  the  ap- 
pearance as  though  discission  had  been  practiced.  In  both  his  cases  the 
anterior  cortical  substance  was  but  slightly  cloudy,  whereas  posteriorly 
there  existed  exquisite  choroideal  cataract.  "The  entire  posterior  corticalis 
simulates  "the  pod  of  a  fruit,"  in  which  the  peculiar  asbestos  gloss  was 
particularly  noteworthy.  Owjng  to  the  scarcity  of  personal  observations, 
I  have  called  on  my  colleagues.  Horner  writes,  "I  find  cataracta  punctata, 
especially  posterior  cortical  cataract,  equatorial  cataract  and  anterior  cor- 
tical cataract.  The  age  of  the  patient  appears  to  influence  varieties.  In 
young  diabetic  individuals  there  appears  to  be  a  more  rapid  disintegration 
of  the  anterior  corticalis,  whereas  in  older  people  (and  in  fact,  in  very  severe 
cases)  the  posterior  corticalis  may  first  be  affected.  According  to  my  ob- 
servations, there  is  no  particular  rule." 

Leber  lays  stress  on  the  same  picture  \\hich  is  observed  in  youthful 
diabetic  patients  and  in  other  rapidly  developing  cataracts  occurring  in 
youthful  individuals.  "The  cloudiness  is  close  'to  the  capsule  and  there  is 
always  a  tumescence  and  shallowness  of  the  anterior  chamber,  but  I  do 
not  find  that  the  anterior  corticahs  is  always  first  involved."  Concerning 
the  cataract  of  a  young  woman  at  present  under  observation  (about  4.000 
cm.  urine,  with  10  per  cent,  sugar)  and  suffering  with  a  high  degree  of 
diabetes,  Leber  writes,  "In  the  right  eye  the  cloudiness  exists  just  as  Horner 
ha.s  described  it,  consisting  of  broad,  bluish,  wavy  sectors;  which,  if  not 
immediately  beneath,  are  at  least  close  to  the  capsule.  Through  this  cloud- 
iness one  can  plainly  see  the  cloudy  striations  in  the  posterior  corticalis. 

iSZwei  Fallo  von  Roidor  Seitigo  Cntaractn  Diabetica.     Arch.  f.  Augen.  Bd. 
VIII. 


223 

On  the  left  eye  the  anterior  corlicalis  is  a.?  good  as  totally  iraiispareiit; 
whereas  the  posterior  shows  the  shell-like  cloudiness,  disclosing  the  deli- 
cate, moderately  broad  striations  of  which  it  is  made  up." 

Dr.  JMax  Perles  ^*  reports  the  following  remarkable  case.  In  a  patient 
sixty-two  years  of  age,  he  discovered  a  very  peculiar  change  in  the  lens. 
By  daylight  the  pupils  give  back  a  peculiar  greenish-black  reflex.  On  focai 
illumination  and  examination  with  the  corneal  loup,  the  anterior  corticaHs 
and  the  nucleus  are  found  to  be  clear.  In  both  eyes,  however,  the  temporal 
portion  of  the  posterior  substance  discloses  an  almost  completely  symmet- 
rical deposit  of  rust-brown  coloring  matter,  which  is  arranged  like  a  closely 
woven  network  of  mycelium.  This  deposit  is  located  immediately  beneath 
the  capsule,  is  most  dense  along  the  temporal  edge,  becomes  thinner  toward 
the  middle,  and  finally  is  lost  in  the  finest  threads.  In  this  network  these 
dark  brown  granules  are  deposited.  Neither  vesicles  nor  droplets,  as  is 
usual  in  beginning  cataract,  can  be  seen.  The  vitreous  is  free  from  cloudi- 
ness; both  eyes  are  emmetropic.  View  of  the  fundus  is  difficult,  but  shows 
no  visible  change.  There  is  no  albumen  in  the  urine,  but  about  7  per  cent, 
of  sugar;  no  abnormal  pigmentation  of  the  skin.  Microscopical  examina- 
tion of  the. blood  shows  the  haemoglobin  normal.  This  pigmentation  of 
the  lens  positively  only  set  in  after  the  diabetes  had  existed  in  this  severe 
form  for  several  years.  Perles  concludes:  "These  changes,  in  all  probabil- 
ity, are  due  to  the  diabetes,  since  a  like  pigmentation  of  the  skin  in  this 
form  of  disease  is  not  unusual.  However,  an  expression  of  opinion  as  to 
the  nature  and  source  of  this  pigmentation  can  not  be  made  until  anatom- 
ical examinations  have  thrown  some  light  on  the  subject." 

Eegarding  the  presence  of  sugar  in  non-eataractous  lenses  of  diabetic 
patients,  we  possess  but  a  single  observation  made  by  Deutschman.^^  j^ 
the  lens  of  a  ten  year  old  girl  who  had  died  of  diabetes,  he  could  not  dis- 
cover any  sugar  in  the  lens,  whereas  the  urine  contained  0.5  per  cent.  From 
the  folloAving  it  will  be  seen  how  important  it  would  be  to  make  a  large 
number  of  analyses  in  analogous  cases. 

In  the  following  table,  arranged  according  to  their  age,  will  be  found 
a  report  of  all  the  accessible  cases  of  diabetic  cataract  in  which  the  lens  was 
examined  for  sugar  after  the  extraction.  Assuming  that  the  table  repre- 
sents all  the  reported  cases  of  diabetic  cataract  extracted  and  examined  for 
sugar,  one  finds  that  in  the  great  majority  of  cases  sugar  was  found  present. 
In^bo'th  of  the  senile  cataracts  extracted  by  me  November  30  and  31,  no 
sugar  was  found.  Since  negative  results  are  reported  for  all  ages,  one 
is  'justified  in  assuming,  that  the  presence  of  sugar  in  cataract  has  nothing 
to  do  with  the  age  of  the  patient,  and  since  at  times  in  the  soft,  rapidly 


14  Pi^uentstaar  bei  Diabetes.     Hirschberg's  Centralblatt.  p.  171.     1892. 

15  Uutersuchun^  zur  Pathogenese  der  Kataract.    Arch.  f.  Opth..  XXIII,  3,  1, 
143. 


2  24 

clouding  and  iuinescent  cataract,  pugar  was  not  found  at  other  times;  hence 
the  variety  of  the  cataract  can  not  be  looked  upon  as  indicating  the  pres- 
ence of  sugar  in  the  lens. 

In  all  the  positive  results,  there  has  been  a  high  percentage  of  sugar 
in  the  urine,  and  in  the  negative  a  low  percentage.  If  one  will  stop  to 
consider  the  large  quantity  of  sugar  voided  the  day  of,  or  the  last  few  days 
previous  to  the  operation,  as  an  indication  of  the  quantity  present  in  the 
blood  and  tissue  fluids;  also,  as  has  been  observed  time  and  again,  that  the 
cataract  formation  only  occurs  w-here  there  is  a  large  excretion  of  sugar, 
hence  one  will  understand  that  in  these  cases,  sugar  will  be  found  in  the 
lens.  From  this  it  would  also  follow  that  sugar  will  not  be  constantly 
present  in  the  lens,  but  will  vary,  depending  on  the  general  condition. 
This  fact  is  particularly  demonstrated  in  Case  4,  No.  25  and  20  of  the  table, 
in  w'hich  special  attention  was  given  to  this  fact: 


Urin. 

f] 

Name  of 

Name  of 
Examiner. 

1 

Opera- 
tor. 

< 

Kind  of  Cataract. 

S.  G. 

Percentage 
of  Sugar. 

a 

I 

Schmidt. 

Zincke. 

15 

F. 

Cataract     hypermatura    re- 
ducta. 

Much  Urine. 

Large  quanti- 

^ 

- 

2 

15 

F. 

Cataract     hypermatura     re- 
ducta. 

Much  Urine. 

ty  of  sugar. 
Large  quanti- 

I? 

3 

Viol. 

16 

F. 

Cataract     hypermatura    re- 

ty  of  sugar. 

i?i 

ducta. 

1040 

Large  quanti- 

4 

16 

F. 

Cataract     hypermatura     re- 
ducta. 

1041 

ty  of  sugar. 
Large  quanti- 
ty of  sugar. 

' 

5 

Jatiy. 

Buchwald. 

17 

M. 

Ant    cortical   delicate,    post 
cortical  dense  cloudiness, 
nuclear  clear. 

0.7-5.61  in  the 
days  of  the 

6 

Muller. 

17 

M. 

Lens     densely     tumescent, 
thick  cloudiness  of  cortex. 

oper  2.0. 

J 

y 

Viol. 

18 

1042 

1 

8 

20 

1045 

9 

Stober. 

Hepp. 

21 

F. 

White,   cloudy,    soft,    tume- 

I 

scent  cataract. 

1041 

4,807 

I 

10 

Jany. 

Muller. 

22 
22 

F. 
F. 

Tumescent  milky. 
Anterior  corticalis  delicately 

1040 

0.15-8.6 

K 
1 

clouded,  posterior  cortica- 

lis   shell-like    cloudiness, 

1 

nuclear  clear. 

1034 

0.15-8.6  3"^ 

•c 

_ 

Hepp. 

23 

F. 

I 

I 

n 

12 

Stober. 

23 

F. 

Soft,    milky. 

1052 

8.8-9.7 

I 

n 

13 
14 

Teillais. 

Cariiis. 

23 
25 

F. 
M. 

Greyish  white  opalesence  to 

1052 

8.8^.7 

J 

° 

15 

Knapp. 

25 

M. 

yellow.   0.5. 
Cataract     hyi)ermatura     re- 

1052 

8.9 

, 

a 

16 

ducta. 

1052 

8.9 

I 

n 

28 

1052 

< 

17 

Viol. 

Klinger. 

31 

M. 

Catar.  nondum  matura  o.  w. 

1052 

7.8               ] 

18 

Berlin. 

31 

M. 

Catar.  nondum  matura  o.  w. 

1052 

7-8 

I 

n 

19 

0.  I^iebreich. 

34 

F. 

Catar.  mollis  matura  o.  w. 

1040 

8.6 

I 

0 

20 

Schmidt. 

34 

F. 

Catar.  mollis  matura  o.  w. 

1040 

8.6 

^ 

35 

M. 

1040 

8.6 

I 

22 

Nagel. 

Kuhne. 

38 

M. 

Both    eyes,    soft    tumescent 

I 

23 

Becker. 

cataract. 

1040 

8.6                I 

38 

M.   Cataract. 

1040 

8.6 

-4 

40 

M.   Both    eyes,    .soft  tumescent 

[   I 

2.S 

40 

cataract. 
M.  Both    eyes,    .soft   tumescent 

1040 

6-7 

I 

2f> 

" 

!     cataract. 

1040 

6.7 

Berlin. 

1-chling. 

40 

Moderately     soft     cataract, 
with  clear  nucleu.s. 

1040 

6.7 

J 

28 

l.tber. 

53 

F. 

Rapidly  developed,    double, 

.soft  cat.,  not  entirely  ripe. 

Broad  mother  of  pearl  stria- 

,.,40 

4-7 

' 

29 

53 

F- 

I 

tions. 

1040 

4-7 

30 

Becker. 

Kuhne. 

62 

F. 

Cataract  senilis  matura. 

1040 

4-7 

I 

63 

F. 

Cat.  .senilis  non  dum  matura. 

1040 

0.1-0.9 

1 

225 

'riirl-cf. 

)i-c,  t(»  -i|iiiiiiiii-i/.(' 

all  tl 

hal  li 

as  liccii  said  ; 

is  the  r< 

■>ull  (d'  personal 

)l)S('r\ati(iii 

and  till-  ol)sci-\ati 

(III  (1 

r  ..tl 

icrs.   one    Wdll 

Id  >a.v  t 

hat  in  youthful 

iudividiials 

ihc  diahi'lic  calai 

■act   ( 

level 

ops  al)(iiil  as 

r..ll..\\>. 

First  there  is 

a  cloudiness  in  the  equatorial  zone  in  most  cases  followed  hy  a  cloudiness  in 
the  posterior  cortical  suhstancc  and  after  this  had  developed  tlie  anterior 
corticalis  is  attacked.  This  rapidly  progresses  to  form  a  soft  cataract,  at 
first  attacking  the  lamellae  immediately  beneath  the  ca])sule.  At  this  time 
there  is  neither  a  tumescence  nor  a  shrinkage  of  the  lens  system,  but  it  i? 
true  that  very  soon  the  star  figure  is  developed.  This  latter  symptom,  as 
in  all  other  soft  cataracts,  I  look  upon  as  the  first  indication  of  the  taking 
up  of  water.  The  tumescence  goes  on  rapidly  and  steadily,  as  the  result 
of  the  taking  up  of  water  in  the  capsule,  and  at  the  same  time  the  lens 
is  fissured  and  split  into  sectors.  The  tumescent  lens  always  shows  a  vers- 
marked  iris  shadow,  because  there  is  a  very  perceptible  layer  of  fluid  be- 
tween capsule  and  lens.  This  condition  may  last  one  or  two  months.  At 
the  end  of  this  time  the  volume  is  reduced,  but  the  iris  reflex  may  remain. 
The  silky  gloss  is  lost  and  a  new  picture,  (that  of  the  cataracta  hyperma- 
tura  reducta  of  senile  cataract),  is  developed.  The  entire  lens  system  is 
reduced.  Schmidt-Eimpler  extracted  and  measured  such  lenses.  Both 
lenses,  Nos.  1  and  2  of  the  above  table  had  an  equatorial  diameter  of  8.5 
mm.;  the  right  a  saggital  diameter  of  2.5  mm.,  the  left  of  2.0  nmi.  (See 
Becker,  Case  No.  2).  From  personal  observation,  I  can  not  state,  nor  have 
I  been  able  to  find  any  statements  in  literature,  as  to  whether  the  diabetic 
soft  cataracts  of  youth  can  become  entirely  fluid;  whether  capsular  cataracts 
may  be  added  to  these,  or  whether  calcareous  deposits  can  take  place.  Ber- 
lin writes  to  me  that  he  operated  a  diabetic  patient  for  a  cataracta  Mor- 
gagniana;  who.  however,  during  the  days  of  the  operation  ha<l  albumen, 
but  no  sugar,  in  his  urine. 

In  the  entire  se(iuence  of  changes  which  take  place  in  diabetic  cata- 
racts, I  can  discern  nothing  which  differs  from  the  ordinary  soft  cataracts 
of  youth  which  occur  in  both  eyes.  Therefore,  it  seeijis  most  probable  that 
the  cataract  results  from  the  entrance  of  a  pathologically  changed  nutritive 
fluid,  resulting  from  the  addition  of  sugar,  along  the  normal  point  of  en- 
trance in  the  equatorial  region,  'i'lu'  only  difference  from  other  constitu- 
tional cataracts  consists  in  the  fact  that  we  believe  that  this  form  is  due 
to  the  ])resence  of  sugar  in  the  vitreous;  whereas  in  the  others  we  have  not 
as  yet  been  enabled  to  se]>arate  the  anoniahuis  substance  in  the  nutritive 
supply. 


2  26 

THE  AETIOLOGY  OF  THE    SO-OALLED    DIABETIC    CATARACT. 

Owing  to  the  fact  tliat  sugar  lias  been  found  in  all  the  tissue  fluids  of 
the  body,  and  since  the  now  famed  experiments  of  Kunde  for  the  expeii- 
mental  production  of  cloudiness  of  the  lens,  entire  series  of  methods  have 
been  devised  to  ex])lain  the  cloudiness  of  the  lens  which  develops  in  dia- 
betes. 

After  Leber  1^  had  expressed  the  hope,  that  our  knowledge  concerning 
the  development  of  diabetic  cataract  would  be  furthered,  by  experimental 
investigation,  Deutschmann  ^"^  and  Heubel  ^^  entered  on  this  task  most  fully. 

Xotwithstanding  the  difference  and  the  relative  values  of  the  methods 
em})loyed  in  making  these  experiments,  and  aside  from  the  animated  dis- 
cussions which  arose  between  Deutschman  and  He'ubel,  it  becomes  a  matter 
of  general  interest  to  note,  that  both  experimenters  are  in  accord  in  stating 
that  the  so-called  salt,  or  sugar,  cataracts  are  produced  by  the  process  of 
diffusion,  between  the  salt  or  sugar  containing  aqueous  (or  vitreous)  on  the 
one  hand,  and  the  lens  on  the  other;  in  consequence  of  which  water  and 
albumen  diffuse  in  the  aqueous,  and  the  nacl,  respectively  the  sugar,  into 
the  capsule  of  the  lens. 

According  to  my  (Becker's)  judgment,  Deutschman's  conclusions  prove 
nothing.  He  placed  a  human  eye,  taken  from  a  corpse,  in  a  5  per  cent, 
sugar  solution  and  after  fourteen  hours  the  lens  became  cloudy,  whereas  in 
a  highly  diabetic  girl  in  whom  there  was  no  cataract,  sugar  was  formed 
in  the  fluid  media  of  the  eye  not  in  excess  of  0.5  per  cent.;  hence  he  denies 
that  the  cataract  can  result  from  the  extraction  of  water  by  means  of  a 
large  quantity  of  sugar  present  in  the  fl'iiid  media  of  the  eye.  Though  no 
weight  is  placed  on  Heubel's  objection  that  experiments  made  on  enucle- 
ated lenses  can  not  be  applied  to  the  living  eye,  he  nevertheless  is  correct, 
beyond  a  doubt,  when  he  draws  attention  to  the  fact,  that  smaller  quantities 
of  sugar  solution  acting  for  a  relatively  longer  time,  may  cause  even  more 


ifi  UlHT  die  Erkrankun^vn  dor  Augeii  bei  Diabetes  Mellitus.  Arcli.  f.  Opth., 
Bd.  XXI,  3. 

17  (1)  Untersuchungen  zur  Tathogenese  der  Cataract.  Areb.  f.  O..  3.  1, 
(2)  Zur  Wirkung  wasser  entziehender  Stoffe  auf  die  Krystallinse.  Arch.  f.  d  ges 
Phys.,  Bd.  XX.  (3)  Entsteh  die  Diab  Kataraot  brim  Meuschen  in  Folge  von 
wasserentziehung  der  Linse  seiteus  zucker  lialtiger  AugcntlussigkeitV  Eiue  Ent- 
gegnuug  an  Prof.  Heubel  in  Kiew.  Arch.  f.  d  ges  Phys.,  Bd.  XXII. 

18  (1)  Uber  die  Wirkung  Wasserentzicliender  Stoffe  insbesondere  auf  die 
Krystallinse.  Arch.  f.  d  ges  Physiol..  Bd.  XX,  p.  111-118.  II  Bemerkungen  zu 
Dentschmann's  Aufsatz.  (2)  Arch.  f.  des  Physiol.,  Bd.  XXI,  p.  153-176.  (3)  Ant- 
wort  auf  Dr.  Deutsc  Innann's  Entgegung.  Arcli.  f.  d.  ges  Physiol..  Bd.  XXII, 
p.  580-590. 


227 

extensive  changes,  than  large  quantities  acting  for  a  short  time.  The  lesser 
quantity  of  the  active  substance  is  compensated  for  by  the  longer  time  it  is 
active. 

"With  all  due  respect  to  Heubel's  talent,  both  as  an  experimental  in- 
vestigator and  critic,  I  feel  called  upon  to  raise  a  few  objections  from  a 
clinical  standpoint,  to  the  application  of  his  experimental  results  to  cataract 
as  observed  in  diabetic  patients." 

"In  his  first  critical  essay,  in  reply  to  Deutschmann,  (2,  above  p.  175), 
he  sums  up  his  views,  stating  that,  "in  the  formation  of  the  true  diabetic 
cataract,  the  sugar  contained  in  the  aqueous  and  vitreous  (be  it  as  such  or 
in  Combination  with  Na.  CI.),  is  of  the  very  greatest  importance,  and 
the  first  and  most  important  change  which  the  lens  undergoes  is  the 
withdrawal  of  water  as  the  result  of  the  action  of  the  sugar."  "The  genu- 
ine diabetic  cataract  develops  in  an  unusual  and  in  a  peculiar,  entirely  dif- 
ferent manner,  and  in  this  mode  of  development  the  aqueous  positively  ex- 
erts an  influence  in  producing  this  cloudiness."  "There  is  a  complete 
analogy  between  the  mode  of  development  of  the  diabetic  cataract  and 
those  cataracts  which  are  experimentally  produced  by  the  dehydrating 
action  of  sugar  and  salt  solutions.  This  cloudiness  always  involves,  first, 
the  external  cortical  layers;  at  the  beginning  the  nucleus  remains  clear  and 
the  surface  of  the  lens  shows  the  sector-like  facetts."  "Competent  observ- 
ers have  stated  that  with  proper  diathetic  and  therapeutic  treatment,  by 
which  the  amount  of  sugar  can  be  considerably  reduced,  the  lens  may  be 
made  to  almost  completely  clear  up  again,  a  condition  which  has  hardly 
ever  been  observed  in  other  forms  of  cataract.  There,  also,  do  we  find  an- 
other remarkable  coincidence  between  diabetic  cataract  and  those  experi- 
mentally produced  by  the  dehydrating  action  of  the  sugar  and  salt  solu- 
tions." 

"One  must  here  note  that  Heubel  lays  particular  stress  on  the  expres- 
sion, 'genuine  dialeiic  cataract.'  By  this  he  can  only  have  reference  to 
the  diabetic  cataract  of  youth  as  described  by  Foerster.  Heubel  possibly 
unconsciously  has  given  up  complete  agreement  with  Foerster,  for  he  states 
that  sugar  in  the  vitreous  may  also  lead  to  cataract  formation.  (Cited  above, 
p.  187.)  He  describes  an  experiment  in  which,  if  the  aqueous  is  permitted 
to  escape,  the  cloudiness  only  appears  at  the  posterior  pole.  But,  aside 
from  this,  I  believe  that  I  have  shown  above  that  "genuine  diabetic  cata- 
ract," as  a  special  variety,  does  not  exist,  but  coincides  in  form  with  the 
majority  of  cataracts  developing  in  youthful  individuals,  as  rapidly  devel- 
oping soft  cataracts,  also  as  to  their  course  and  final  end.  Heubel's  argu- 
ments, based  on  the  experimentally  produced  cataracts  and  their  subsequent 
clearing  up,  is  even  on  a  weaker  basis.  The  cases  on  which  Heubel  bases  his 


2?S 

arguinents  (cited  above  Xo.  1,  p.  176,  II,  17(5),  Becker  reported  years  ago.^^ 
Seegen's  case  ^^*  occurred  in  a  man  39  years,  of  age;  Gerhardt's  in  a  woman 
56  years;  and,  according  to  Foerster's  statement,  these  could  not  have  been 
eases  of  genuine  diabetes,  since  they  do  not  occur  past  the  middle  of  the 
twenties.  Ileubel  himself  states  that  "hardly  ever"  has  a  non-diabetic 
cataract  been  known  t(^  clear  up.  "Will  anyone  think  hard  of  it,  if  oculists 
refuse  to  accept  this  fact  as  .proven?  I  hardly  doubt  that  both  Gerhardt 
and  Seegen  will  aclaiowledge  the  possibility  of  their  having  made  a  mis- 
take. At  the  same  time,  one  must  not  doubt  but  that  vision  was  improved 
by  Carlsbad  salts.  It  has  simply  not  been  proven  that  a  disappearance  of 
cloudiness  of  the  lens  bettered  vision.  It  is  far  more  probable  that  this 
was  due  to  a  clearing  up  of  the  vitreous  and  the  improvement  of  a  case  of 
retinitis:  causes  which  ought  not  to  be  set  aside." 

lu  his  reply  Heubel  drew  attention  to  two  other  possibilities.  Zehender's 
remarks  did  not  escape  him,  namely,  that  the  soft,  tumescent  condition  of  most 
diabetic  cataracts  seemed  to  refute  the  idea  that  there  is  a  withdrawal  of  water 
from  the  lens.  This  thought,  later  taken  up  by  Jany  and  myself,  was  answered 
by  Heubel  (one  cited  above),  by  his  drawing  attention  to  the  fact  "that  in 
beginning  cloudiness  and  in  new  cases  the  dehyration  is  but  partial,  is  re- 
stricted to  a  small  portion  of  the  lens;  whereas,  the  remainder  of  the  lens  sub- 
stance i-etaius  its  normal  or  possibly  a  reduced  consistency."  Heubel  considers 
it  as  more  than  probable,  that  as  tlie  result  of  the  withdrawal  of  water  the 
changed,  cloudy  (ov  shrunken)  "lensrads,"  after  the  lapse  of  a  certain  length 
of  time,  even  where  there  is  abundant  addition  of  water,  can  not  be  cleared  up 
again;  and  after  diabetic  cataract  has  existed  for  a  certain  length  of  time,  such 
manifold  changes  do  not  set  in  as  can  easily  lead  to  a  soft  and  watery  con- 
sistence of  the  cloudy  lens  substance."  As  a  fact,  one  must  acknowledge  that 
in  soft  diabetic  cataract,  as  in  any  other  spontaneously  developing  cataract,  the 
tumescence  is  the  first  stage  of  cataract  formation. 

In  his  first  essay  on  this  subject  Deutschman  pointed  out  tlie  fact  that  the 
microscopical  conditions  noted  in  the  experimentally  produced  salt  and  sugar 
cataracts  does  not  coincide  with  those  of  the  true  diabetic  cataract.  True,  at 
that  time  he  only  had  for  comparison  the  short  comiuunication  of  Knapp  20 
concerning  the  condition  of  extracted  diabetic  cataract.  Here  I  must  again 
agree  with  Heubel  (two  above).  "We  can  scarcely  form  an  idea  as  to  the  man- 
ner in  which  diabetic  cataract  develops  by  examining  a  diabetic  cataract  in  its 
latter  stages."  There  is  always  this  difference,  the  experimentally  produced 
diabetic  cataract  develops  acutely,  whereas  the  diabetic  cataract  develops  in 


19  Pathologic  and  Therapie,  p.  272. 
19a  Der  Diabetes  :Mellitus.    Leipsig.  1870.  p.  212. 

20Bericht  uber  ein  siebentes  hundert  Staar  oxtractionon.    Arch.  f.  Opthal., 
Bd.  XII,  p.  49. 


229 

a  chronic  manuer;  hence,  it  seems  que^^tiouJlble  to  lue,  though  it  would  he  pos- 
j^ible  to  examine  microscopically  a  developing  diabetic  cataract  in  its  capsule, 
whether  one  would  even  be  able  to  formulate  a  theory  which  could  not  be 
attacked.  Our  science  is  certainly  deeply  indebted  to  Heubel  for  the  thorough 
and  objective  criticism,  and  the  manner  in  which  he  refuted  Claude  Bernard's 
hypothesis,  that  cataracta  Aiahctica  is  solely  and  alone  due  to  the  increased 
amount  of  sugar  in  the  blood. 

In  1887,  Deutschman  again  took  up  this  siibject,^!  and  formulated  the 
following  hypothesis  as  to  the  genesis  of  'this  form  of  cataract.  He  states, 
''Owing  to  the  dyscrasia,  the  lens,  which  is  an  epithelial  structure,  is  subject 
to  the  same  disintegration  as  other  epithelium.  The  lens  fibres  undergo 
the  same  local  death  as  does  the  epithehum  of  the  kidney,  and  with  this 
death  of  the  cells  begins  the  anomalous  process  of  diffusion;  but  the 
moment  the  lens  iibres  begin  to  die,  just  as  in  the  cadaverous  lens,  changes 
follow  in  consequence  of  the  processes  of  diffusion,  and  cloudiness  and 
tumescence  of  the  lens  follows.  Hence  I  assume  a  primaiy  death  of  the 
lens,  which  is  an  epithelial  structure,  in  diabetic  cataract.  This  must  not 
necessarily  be  a  total  death;  a  partial  death  is  sufficient  to  permit  of  a 
change  in  the  process  of  diffusion.  I  am  opposed  to  the  theory  of  "the 
withdrawal  of  water  from  the  lens." 

Likewise,  Leber,  by  demonstrating  that  the  fluid  media  in  diabetes 
have  an  alkaline  reaction,  has  refuted  Lohmeyer's  hypothesis,^^  that  sugar 
in  the  aqueous  and  vitreous  becomes  changed  into  lactic  acid,  and  the 
action  of  this  leads  to  the  cloudiness  of  the  lens,  hence  we  are  as  far  today 
as  ever  from  finding  the  intermediate  link  between  the  pathological  condi- 
tion in  which  sugar  is  found  in  the  nutritive  fluid  and  the  cloudiness  of  the 
lens.  In  the  case  of  the  diabetic  cataract,  we  are  no  fai-ther  than  in  other 
forms  of  constitutional  cataract. 

There  is  an  entire  series  of  constitutional  diseases,  in  which  the  con- 
stitution of  the  blood  and  lymph  is  altered,  hence  in  which  the  lens 
receives  an  abnormally  constituted  nutritive  material,  which  in  some  cases 
leads  to  cataract  formation.  Diabetes  mellitus  belongs  to  this  class  of 
diseases. 

PROGNOSIS  OF  CATARACT  OPERATIONS  IN  DIABETES. 
•'•Even  at  the  present  day  some  operators  look  upon  operations  for  cataract  in 
diabetic  patients  as  offering  a  poor  prognosis.  This  is  evident  from  the  oft- 


21  Pathologisch-Anatomische  Untersuchungen  Augen  von  Diabetikern,  nebst 
Bemerkungen  uber  die  Pathogenese  der  Diabetischen  Cataract.  Graef  Arch., 
XXXIII,  Bd.  2.    1887. 

22  Beitrag  zur  Histologie  und  Aetiologie  der  Erworbenen  Linsenstaare.  Zeit- 
schrift  fur  Rationale  Medicin.,  N.  F..  Bd.  V.  p.  99.   1854. 


2  30 

repeated  printed  statement,  "Luckih-  operated."  As  is  well  known,  Von 
Graefe  was  very  guarded  in  his  statements,  and  though  others,  as  well  as 
myself,  have  pointed  out  the  fact  that  the  incision  even  in  very  emaciated 
diabetic  patients,  heals  very  kindly,  nevertheless,  Jany  advises,  after  a 
peripheral  incision,  the  extraction  he  made  by  suction  subsequent  to  a  pre- 
liminary discission.  But  if  any  one  will  read  Jany's  description  of  his  four 
cases  operated  in  this  manner,  he  can  only  conclude  that  eyes  which  can 
undergo  such  manipulations  are  really  less  vulnerable  than  healthy  eyes 
in  which  an  ordinary  senile  cataract  has  developed.  From  a  large  number 
of  experienced  operators,  I  have  been  privately  informed  that,  just  in 
diabetes,  an  unusually  good  process  of  healing  follows.  It  is  possible  that 
the  presence  of  sugar  in  the  lymph  causes  the  edges  of  the  wound  to  be- 
come rapidly  agglutinated.  The  only  possible  complication  (where  the 
operation  is  correctly  done)  is  an  iritis.  This  has  occurred  once  to  me; 
also  to  Horner,  and  likewise  to  Leber.  Snellen  writes  to  me,  "I  often  find 
the  pigment  at  the  edge  of  the  pupil  very  loose,  as  in  macerated  eyes."  I 
(Becker,  "Pathologie  and  Therapie,"  p.  272)  before  this  time  had  drawn 
attention  to  this  fact,  namely,  that  in  cases  of  tumescent  diabetic  cataract, 
the  pigment  around  the  edge  of  the  pupil  is  very  broad,  and  that  even  after 
an  iridectomie  the  same  condition  is  noted  along  the  edges  of  the  colo- 
boma.  This  peculiar  condition  of  the  iris,  and  the  hemorrhages  into  the 
vitreous,  even  though  extremely  slight,  indicate  that  a  diabetic  cataractous 
eye  is  not  only  a  diseased  eye,  but  possibly  also  explains  the  occasional 
occurrence  of  iritis  after  an  extraction." 

There  is  another  circumstance  to  which  I  desire  to  call  attention.  In 
the  literature  on  this  subject  I  find  four  cases  reported,  in  which  a  few  days 
after  a  cataract  extraction,  the  patient  died  of  diabetic  coma.  One  ought 
to  tell  the  relatives,  as  well  as  the  patient,  of  the  possibility  of  such  a  termin- 
ation, in  consequence  of  the  excitement  incident  to  an  operation  and  the 
dietary  restrictions  which  become  necessary. 

E. 
CATARACTA  SENILIS  PEAEMATURA. 

Between  the  soft  cataracts  of  youth  and  the  senile  cataract,  a  form  of 
cataract  develops  which  occupies  a  mediam  place  between  the  two  forms, 
both  as  to  the  time  of  its  development  and  its  seat  in  the  middle  of  the 
lens.  The  aetiology  seems  to  be  closely  linked  with  a  general  reduction  of 
the  nutrition  of  the  body.  Foerster  considers  the  cause  of  the  cataract 
formation  to  be  a  premature  marasmus  of  the  body.  He  also  draws  atten- 
tion to  Hogg's  statement  of  the  frequent  coincidence  of  urethral  stricture 
and    hypertrophy    of    the    prostrate    with    the    marasmus     praematuris, 


231 

(among  50  patients,  he  found  IT  cataract  cases).  However,  this  does  not 
prove  an  exact  relationship  between  the  two.  There  is,  likewise,  a  total 
absence  of  symptoms  by  means  of  which  one  may  with  certainty  recognize 
tlie  premature  marasmus  or  premature  senility.  Up  to  this  time,  it  has 
not  been  possible  to  do  more  than  make  some  general  statements.  Never- 
theless, Becker  states,  he  has  attempted  to  make  a  diagnosis  of  such  a  cata- 
ract from  the  manner  of  its  development. 

CATARACTA  (SKNIIJS  PKAEMATUEA)  NUCLEATMS. 

This  form  of  cataract  characterizes  itself  by^  developing  in  the  nucleus 
of  the  lens,  between  the  fortieth  and  fiftieth  year,  a  time  of  life  when  the 
sclerosis  of  the  nucleus  of  the  lens  is  already  far  advanced;  and  this  cloudi- 
ness gradually  extends  into  the  transparent  cortical  substance.  It  has  a 
peculiar  white,  almost  milky,  color.  This  cataract,  at  an  exceedingly  slow 
rate,  finally  becomes  a  total  cataract.  The  individuals  show  in  their  gen- 
eral appearance  that  their  health  has  been  disturbed  for  a  long  time.  They 
are  people  who  have  been  reduced  by  general  marasmus,  disease,  excessive 
bodily  exertion,  many  and  difficult  labors,  material  want,  grief,  and  care; 
and  frequently  the  clinical  history  shows  that  the  patients  (women)  have 
suffered  from  hysterical  convulsions. 

Becker  states  that  he  has  only  been  enabled  to  examine  teased  speci- 
mens of  extracted  cataracts  of  this  form,  but  has  not  been  able"  to  discover 
any  distinctive  peculiarity.  A  positive  judgment  must  be  withheld  until 
a  complete  eye  containing  such  a  cataract  can  be  examined.  In  his  "Path- 
ology and  Therapie,"  ^3  he  suggested,  that  possibly  a  chemical  examina- 
tion might  throw  some  light  on  the  subject. 

He  further  suggests  ^^  the  possibility  that,  in  contradistinction  to  all 
other  conditions,  there  has  never  been  a  true  formation  of  a  nucleus  in  a 
lens  which  becomes  diseased  in  this  manner.  It  would,  then,  not  be  a 
'difficult  matter  to  understand  how,  owing  to  this  exceptional  condition  of 
the  lens,  there  should  follow  a  peculiar  cataract  formation. 

Without  in  such  cases  being  able  to  demonstrate  a  diseased  condition 
of  the  nutritive  fluids  of  the  entire  body,  (since  we  find  neither  albumen  nor 
sugar  in  the  urine),  we  might  look  upon  the  general  marasmus  of  the  en- 
tire body  as  the  cause  of  a  failure  to  form  the  nucleus.  The  subjective 
symptoms  are  those  of  so-called  nuclear  cataract.  The  prognosis  is  not 
as  good  as  in  simple  senile  cataract.  It  is  not  dependent,  even  partially,  on 
the  general  condition  of  the  individual,  nor  on  the  general  tendency  of 

23  S.  73,  p.  270. 

24  S.  73,  p.  270. 


232 

the  healing  of  wounds;  but  on  the  fact  that  the  outer  non-cloudy  lamellae 
of  cortical  substance  necessarily  remain  behind  in  the  eye,  or  are  reinoved 
with  difficulty.  In  no  other  form  would  Von  Mutter's  proposal— to  punc- 
ture the  capsule,  so  as  to  hasten  ripening  of  the  cataract — be  as  applicable 
as  in  this  form.  In  such  cases  it  would  be  worth  the  attempt,  in  advanced 
cases,  to  practice  discission.  At  the  present  day,  no  doubt,  artificial  matura- 
tion would  be  practiced. 

SENILE  CATARACT.     CATARACTA  SENILIS. 

As  the  name  indicates,  this  form  of  cataract  occurs  in  the  aged,  and 
as  a  rule  one  should  hesitate  to  designate  a  cataract  as  senile  if  the  patient 
has  not  passed  the  fiftieth  year.  It  is  not  correct  to  state  that  an  earlier 
ageing  of  the  entire  body  would  predispose  to  senile  cataract.  There  are 
no  observations  reported  where  in  so-called  "youthful  aged  ones"  an  earlier 
sclerosis  of  the  lens  occurred  or  developed  more  rapidly  than  under  normal 
conditions. 

Just  as  far  as  the  sclerosis  of  the  lens  extended  at  the  time  the  cataract 
formation  began,  just  so  far  will  the  lens  remain  as  good  as  unchanged  dur- 
ing the  entire  time  those  processes  take  place  which  are  associated  with  and 
take  place  during  cataract  formation.  In  consequence,  after  extraction  we 
find,  even  in  the  most  varied  forms  of  senile  cataract,  that  the  nucleus  is 
bi-eonvex,  more  or  less  intensely  yellow,  or  even  red;  always  transparent, 
but  not  eataractous.  Both  Malgaigne  and  Foerster  pointed  out  the  fact  that 
in  senile  cataract  the  cloudiness  develops  first  in  the  cortical  substance,  but 
this  did  not  receive  the  deserved  recognition. 

In  the  second  part  of  this  work,  the  pathology  and  the  most  important 
forms  of  senile  cataract  were  so  exhaustively  considered  that  a  short  resume 
of  the  clinical  data  at  this  point  will  suffice. 

The  very  first  recognizable  signs  during  life,  of  a  beginning  senile  cat- 
aract, are  the  very  delicate  fissures  in  the  deeper  portions  of  the  cortical 
substance,  which  totally  reflect  the  light.  These  are  followed  by  the 
'"riders,"  which  develop  in  the  equatorial  region.  These  cloudy  striations 
are  due  to  the  presence  of  a  chemically  changed  fluid  which  accumulates 
in  the  interspaces  as  the  result  of  processes  of  diffusion  going  on  between 
this  fluid  and  the  lens  fibres.  This  fluid  had  an  index  of  refraction  differ- 
ing from  that  of  the  neighboring  lamellae.  The  cause  of  this,  formation 
of  interspaces  is  to  be  found  in  the  pathological  shrinkage  of  the  nucleus, 
which  seems  to  be  a  preparatory  condition  to  the  formation  of  catiiract. 
As  a  rule  these  interspaces  make  their  first  appearance  in  the  cortical  sub- 
stance, in  the  equatorial  region,  because  in  the  region  of  the  poles  both 


233 
capsule  and  corlc.x  oin  more  casil)  follow  ilic  shiMiikino-  nucleus  than  along 
the  equatorial  zone,  ulicic  the  zoinil.i  of  zinii  exerts  traction  in  an  opposite 
direction.  As  a  result  of  (lilTii.-ioti  between  tliese  spaces  and  the  contents 
of  the  fihres,  the  latter  >iinci-  changes  which  lead  to  molecular  disintegra- 
tion. 

During  the  lime  these  processes  are  going  on,  pos>il)ly  cvi'u  preceding 
them,  without  exception,  hyperplasia  of  the  capsular  epithelium  is  pro- 
gressing, which  is  looked  npon  as  an  atrophic  liyperplasia. 

The  general  picture  which  these  striated  opacities  in  the  cortical  sub- 
stance present  at  this  time,  whether  observed  by  the  direct  illumination 
with  the  mirror  or  by  focal  illumination,  is  always  that  of  the  well-known 
arrangement  of  the  lens  fibres.  The  careful  observation  of  this  gradually 
developing  total  opacity  of  the  cortical  substance  which  surrounds  the 
sclerosed  nucleus,  has  led  oculists  to  a  series  of  names  which  designate  the 
condition  of  the  cataract. 

As  long  as  the  above  anatomically  described  condition  persists  and  but 
few  cloudy  striations  appear  in  the  periphery,  either  in  front  of  or  behind 
the  nucleus,  one  speaks  of  a  beginning  cataract  (rafaracla  incipiens).  Where 
this  cloudiness  has  advanced  further,  we  use  the  expression,  "unripe  cata- 
ract," (caiaracta  noncluin  mainra).  Although  there  can  be  no  sharp  line 
of  demarcation  between  these  two  stages,  nevertheless  they  can  be  kepi 
apart  by  speaking  of  caiaracta  incipiens  as  long  as  the  greater  portion  of 
the  cortical  substance  is  not  cloudy.  When  the  entire  cortical  substance 
has  become  totally  cloiuly.  we  speak  of  caiaracta  matura.  At  times,  a 
further  distinction  is  made:  a  stage  immediately  preceding  that  of  ripe- 
ness is  described  as  cataracta  maturesrcns.  The  molecular  disintegration 
of  the  lens  fibres  is  accompanied  by  a  tumescence  or  swelling  of  the  lens, 
due  to  the  taking  up  of  water,  and  this  process  may  go  on  more  or  less 
rapidly.  This  may  proceed  so  rapidly  and  the  polar  diameter  of  the  lens 
so  increase,  as  to  become  evident  to  the  naked  eye;  and  press  the  iris  for- 
ward, so  as  to  lessen  the  depth  of  the  anterior  chamber. 

This  taking  up  of  water  is  followed  by  a  giving  ofT  of  the  same:  the 
tumescence,  by  a  reduction  in  volume.  If  from  the  depth  of  the  anterior 
chamber  one  can  judge  that  the  size  of  the  lens  is  etjual  to  that  of  a  normal 
lens  we  call  this  a  caiaracta  waliira.  when  this  has  fallen  below  the  normal 
volume  we  speak  of  an  over-ripe  cataract,  caiaracta  hi/pennalttra. 

The  stage  of  ripeness  is  recognized,  on  focal  illumination,  by  the  sign-, 
that  one  can  no  longer  recognize  dark  sectors:  and  on  using  the  op- 
thalmoscope.  even  when  the  pupil  is  dilated,  we  no  longer  get  a 
red  reflex  from  the  fundus.  One  must,  however,  direct  attention  to  the 
most  anterior  lamellae,  since  these  are  of  the  greatest  importance.     Owing 


334 

to  the  extreme  thinness  of  the  capsule  of  the  lens,  the  pigmented  edge  of  the 
iris  will  seem  to  lie  in  contact  with  the  lens  when  the  cortical  substance  is 
totaJly  opaque.  If  transparent  cortical  substance  is  still  present  behind 
the  iris,  on  focal  illumination  a  black  interspace  will  appear  between  the 
pupillary  edge  of  the  iris,  and  the  most  anterior  lamellae  which  reflect  the 
light.  This  is  known  as  the  projected  iris  shadow,  and  by  this  means  one 
can  determine  how  much  cortical  substance  still  remains  non-cloudy. 

The  ancient  operators  observed,  that  where  the  lens  had  become  completely 
cloudy,  it  would,  comparatively  speaking,  be  as  easily  removed  from  its  cap- 
sule as  a  ripe  fruit  be  shelled  out  of  its  pod;  hence  the  expression,  "ripe  cata- 
ract. And  this  is  found  in  the  writings  of  Baron  Wenzel,  the  father  (1.  c,  p.  14); 
also  of  Percival  Pott,  1779  (Morgagni,  XIII,  18).  It  appears  after  the  expres- 
sion "ripe  cataract"  had  for  a  time  fallen  into  discredit,  it  again  came  into 
jgeneral  use,  and  in  reality  there  can  be  no  objection  raised  to  its  use,  if  we 
associate  its  use  with  a  well  defined  condition,  such  as  was  described,  and  for 
which  we  are  indebted  to  Arlt  (1.  c,  p.  260). 

Our  knowledge  concerning  senile  cataract  has  advanced  in  more  ways 
than  one.  We  are  indebted  to  Priestly  Smith  for  one  important  step  for- 
ward. He  succeeded  in  demonstrating  that  the  cloudiness  in  the  senile 
lens  is  preceded  by  a  reduction  in  its  volume.  This  shrinkage  of  the 
nucleus,  which  I  had  looked  upon  as  proceeding  to  a  like  degree  in  all  sim- 
ilar lenses,  and  which  I  had  utilized  to  explain  the  occurrence  of  the  first 
fissures  and  splits  in  the  equatorial  region  as  the  result  of  the  fixed  position 
of  the  equatorial  region  in  consequence  of  the  zonula  zinii,  is  now  shown  to 
he  developed  to  a  greater  degree  in  those  lenses  which  later  on  lecome  cata- 
radous,  than  in  those  which  remain  clear.  ' 

On  pages  66,  67  it  has  been  shown  that  the  nucleus  of  a  senile  cataract 
has  a  different  chemical  constitution,  than  the  senile  nucleus  of  the  non- 
cataractous  lens.  Hence  one  might  assume  that  the  cause  of  the  increased 
shrinkage  of  the  nucleus  is  due  to  its  abnormal  chemical  constitution.  But 
since  this  has  only  been  proven  in  the  case  of  cholesterine  and  only  as  ex- 
ceedingly probable  for  albumen,  (Cahn,  Knies);  hence  it  yet  remains,  to 
make  the  same  chemical  analyses  of  the  nuclei  of  senile  non-cataractous 
lenses,  so  as  to  compare  the  two. 

"According  to  Jaeobson  and  Cahn,  we  may  assume  that  both  the  cho- 
lesterine and  the  modified  albuminous  substance  are  not  carried  into  the 
lens  from  without  by  the  nutritive  stream,  but  are  developed  from  the 
albuminous  substances  which  are  normally  present  in  the  lens.  Since  the 
changes  which  take  place  begin  in  the  nucleus  of  the  lens  (hence  in  its 
oldest  and  inmost  lamellae),  and  no  doubt  proceed,  just  as  do  the  normal 
processes  of  sclerosis,  very  slowly;  hence  we  may  draw  the  surprising  con- 


235 
elusion  that  the  preparation  for  the  formation  of  senile  cataract  has  been 
going  on  for  a  long  time.  That  is,  the  beginning  of  the  abnormal  chemical 
changes  in  the  nucleus  of  the  lens,  which  are  a  departure  from  the  normal 
sclerosis  of  the  ageing  lens,  and  ivhich  lead  to  the  senile  cloudiness  of  the  lens, 
do  not  coincide  in  time,  to  the  period  when  we  observe  the  first  cloudiness 
at  the  border  line  between  nucleus  and  cortex,  but  precede  this  by  many  years. 
Whether  or  not  a  person  shall  become  affected  with  cataract  in  his  sixtieth 
year,  in  all  probability  is  dercided  at  forty.  Stress  has  already  been  laid  on 
the  fact,  that  senile  cataract  always  occurs  on  both  eyes,  though  one  lens 
may  be  affected  somewhat  later  than  the  other.  The  cause  of  this  must  be 
sought  in  an  altered  constitution  of  the  nutritive  fluids  of  the  entire 
organism.  True,  we  do  not  as  yet  know  what  this  something  is.  This  is 
probably  to  be  explained  by  the  fact,  that  we  have  not  as  yet  sought  at  the 
proper  time  or  place,  when  this  preparation  for  the  future  cataract  forma- 
tion is  going  on.  It  is  just  possible  that  these  departures  from  the  normal, 
which  later  on  lead  to  cataract  formation,  might  be  found  in  the  lenses 
of  persons  just  reaching  the  age  in  life  when  presbyopic  functional  symp- 
toms manifest  themselves,  and  just  in  those  lenses  which  apparently  one 
would  suppose  would  remain  perfectly  clear,  even  in  very  advanced  old  age. 
It  is  certainly  more  than  a  mere  coincidence  that  just  those  processes,  which 
take  place  in  the  nucleus  of  a  premature  senile  cataract,  and  which  differ- 
entiates it  from  the  senile  cataract,  should  occur  just  in  these  years,  when 
we  suppose  this  preparation  for  the  formation  of  a  senile  cataract  is  taking 
place." 

The  question  of  hereditary  predisposition  to  cataract,  might  likewise 
be  elucidated,  if  we  would  try  to  discover  a  common  constitutional  pe- 
culiarity. If  one  finds  a  family,  as  I  have,  in  which  the  grandmother  de- 
veloped double  senile  cataract  without  any  known  complication,  at  57 
years,  the  father  at  48  years,  and  the  son  at  26  years,  one  can  not  help 
thinking  that  there  must  be  some  hereditar}'  constitution  cause. 

The  subsequent  taking  up  of  water  is  not  inconsistent  with  Priestly. 
Smith's  assertion.  The  taking  up,  is  to  be  looked  upon  as  a  process  of 
diffusion  going  on  between  the  fluid  media  of  the  eye  and  the  already 
partially  cloudy,  hence  chemically  changed,  lens.  This  is  looked  upon  as 
the  second  stage  of  senile  cataract  formation. 

THE  AETIOLOGY  OF  SENILE  CATARACT.  As  we  have  seen, 
there  is  a  chemical  and  a  physical  difference  between  the  nucleus  of  a  sim- 
ple senile  lens  and  the  nucleus  of  a  senile  cataract.  As  a  result  of  this 
chemical  difference,  as  Priestly  Smith  has  shown,  there  is  an  increased 
shrinkage  of  the  nucleus  of  the  lens,  which  later  on  is  to  be  attacked  by 
cataract, and  this, on  the  other  hand, has  given  additional  support  to  Becker's 


236 

theory.  The  anatouiieal  proof  of  the  hyperplnsia  of  the  intracapsular  cells 
which  invariably  accompanies  the  formation  of  senile  cataract,  aside  from 
the  above,  is  in  accord  with  the  theory  of  shrinkage. 

ALBUMIN URJ A  AS  A  CAUSE  OF  SENILE  CATARACT. 

"Deutschman,  since  he  found  albumen  in  the  urine  of  a  large  pei'cont- 
age  (33  per  cent.)  of  patients  suffering  from  senile  cataract,  attempted  to  set 
up  a  s])ecial  form  of  cataract — cataracta  nephrUica.  After  attention  was 
drawn  to  this  fact,  the  percentage  in  my  clinic  also  rose;  thus,  in  1881  it 
was  2  per  cent.,  whereas  in  1882  it  was  18.8  per  cent.  Though  chronic 
nephritis  does  occur  frequently  in  old  people,  this  does  not  by  any  means 
prove  that  there  is  a  causative  relationship  between  the  two.  And  if  the 
above  explanation,  as  to  the  time  when  the  basis  is  laid  for  the  later  devel- 
oping cataract,  is  not  totally  erroneous,  the  mere  fact  that  both  these  dis- 
eases are  present  at  the  same  time,  does  not  by  any  means  prove  a  causative 
relationship  between  the  two." 

"Although  chronic  nephritis  and  albuminuria  belong  to  the  constitu- 
tional diseases,  which,  as  we  know,  may  at  times  lead  to  deep-seated  antl 
almost  always,  disease  of  both  eyes,  and  which  may  easily  affect  the  consti- 
tution of  the  vitreous,  for  the  present,  at  least,  the  causative  relation  be- 
tween chronic  nephritis  and  cataract  can  not  be  looked  upon  as  proven." 

ATHEROMA  OF  THE  C'AKOTID  AS  A  CAUSE  OF  CATARACT. 

"Michel's  statement,-^  "that  atheroma  of  the  carotid  is  a  very  intimate 
causative  factor  in  the  production  of  senile  cataract,  as  well  as  in  the  pro- 
duction of  cataract  in  one  eye,"  seems  to  find  but  slight  support,  in  fact. 
Based  on  a  collection  of  the  cases  reported,  and  a  few  experiments  of  his 
own  and  clinical  histories,  some  with,  some  without,  post  mortem  exam- 
ination, Michel  assumes  as  proven,  that  pronounced  interference  with  the 
circulation  in  the  carotid  may  cause  very  great  interference  in  the  eye  on 
the  same  side;  and  he  further  believes  that  where  the  circulation  in  both 
carotids  is  interfered  with  for  a  long  time,  this  will  gradually  lead  to  an 
increase  of  those  pathological  processes  which  characterize  themselves  by 
interference  with  the  nutrition  of  the  eye.  Michel  says  atheroma  of  the 
carotid  is  such  a  disease,  and  such  a  nutritive  disturbance  leads  to  cataract." 

"Michel  goes  on  to  state,  "owing  to  the  rigid  walls  of  the  arteries,  the 
pulse  waves  are  not  carried  sufficiently  far,  and  in  consequence  of  the  loss 

25  Das  verbalten  dcs  Auges  bei  storungon  ini  Circulationsgebiot  der  Carotis 
in  Beitrago  zur  OitTli.-iliiioloiiif  .-ils  F('st;ia1i('  fur  I-'ricdi-idi  HonitT.  Wifslcidoii, 
;881. 


1 


237 
of  elasticity,  the  column  of  blood  is  not  propelled  onward.  Hence,  a  certain 
slowing  vp  of  the  niorenienf  of  the  hlood  foUoirs,  and,  as  a  result,  changes 
of  nutrition  follow. 

It  is  easily  seen,  that  the  explanation  is  based  on  a  false  premesis,  for 
ceteris  paribus,  a  column  of  fluid  will  rise,  not  slower,  but  more  quickly  in 
a  rigid  tube;  but  when  fhe  propelling  force  acts  periodically,  the  column 
will  not  ascend  continuously,  but  intermittently.  When  fluid  is  forced  into 
a  tube  periodically  it  will  also  flow  out  periodically,  since  the  same  amount 
of  fluid  must  flow  out  at  the  one  end  of  a  tube  as  is  forced  in  at  the  other 
end,  under  a  certain  degree  of  pressure.^^  However,  in  rigid  tubes,  the 
changes  in  the  degree  of  pressure  is  greater  than  in  elastic  tubes.  Where 
the  outflow  is  not  a  free  one,  the  conditions  are  not  the  same.  Where  the 
interference  is  very  great,  the  advancement  of  the  column  of  blood  is  slowed, 
and  the  blood  in  the  left  heart  is  under  heavier  pressure.  In  atheroma, 
owing  to  the  diminution  of  the  lumen  of  the  smaller  arteries  and  capillaries, 
this  resistance  is  increased.  Whereas  an  atheromatous  degeneration  of  the 
vessels  of  the  eye,  whether  this  be  combined  with  an  atheroma  of  the  caro- 
tid or  not,  would  influence  the  nutrition  of  the  eye,  more  especially  the  lens. 

''However,  notwithstanding  the  want  of  a  proper  explanation,  the  con- 
nection between  atheroma  of  the  carotid  and  cataract  is  still  pointed  out, 
hence  I  have  had  the  last  fifty-three  patients  taken  up  at  the  clinic  for 
spontaneously  developed  cataract  examined  in  tliis  regard  in  order  to  test 
Michel's  statements.  I  was  all  the  more  induced  to  do  this,  owing  to  an 
experiment  known  to  me  which  appeared  to  have  some  direct  bearing  on 
the  connection  between  one-sided  atheroma  and  cataract  on  the  same  side, 
and  which  seems  entirely  to  have  escaped  Michel's  notice.  Heubel  ^^  writes: 
"One  can  easily  bring  about  a  cloudiness  of  the  lens,  truly  only  after  the 
death  of  the  rabbit,  if  one  injects  a  concentrated  sugar  solution  in  the 
peripheral  end  of  the  common  carotid.  Death  nearly  always  follows  im- 
mediately after  the  injection,  but  simultaneously  or  a  few  minutes  later 
one  always  observes  the  lens  on  the  same  side  assume  at  first  a  faint,  grad- 
ually-increasing cloudiness,  and  hence  one  may  assume  that  this  form  of 
cataract  develops  just  as  it  do€S  in  the  rabbit." 

"Perhaps  I  would  not  have  decided  to  place  my  negative  results  oppo- 
site the  positive  results  of  Michel  were  it  not  for  the  recent  publication  of 
a  dissertation  by  Marion  von  Karwat,  written  under  ^lichel's  direction,-*  and 
which  indicates  that  even  at  the  present  day  he  holds  fast  to  his  conclu- 

26  See    RoUet,  Physiologie  der    Blutbewegunjr    in    Herman.  Handbuch    der 
Physiologie.  IV.  1.  p.  177. 

27  Quoted  above.  1,  p.  164. 

28  Beitrage  zur  Erkrankung  des  Auges  bei  Carotis  atheroai.    Wurzburg.  18S3. 


238 

sions,  and  if  according  to  an  observation  of  Mooren's  he  did  not  look  upon 
this  as  a  proven  fact.  In  his  "Funf  Lnstren  Opthalmologischer  Wirk- 
samkeit"  he  says  (page  197):  ''Michel's  beautiful  experiments  have  proven 
to  us  the  connection  between  the  development  of  cloudiness  of  the  lens 
and  sclerotic  (atheromatous)  changes  in  the  walls  of  the  carotid."  Such 
a  thoughtless  assent  on  the  part  of  Mooren  becomes  all  the  more  con- 
spicuous, because  Mooren^s  gtates  that  atheroma  of  the  carotid  is  the  cause 
of  senile  cataract.  Michel,  however  (p.  45),  purposely  avoids  stating  that 
the  condition  of  affairs  are  such,  but  that  there  is  a  direct  connection  be- 
tween cloudiness  of  the  lens  and  atheroma  of  the  carotid,  but  not  that 
where  this  condition  exists,  there  is  also  a  like  change  in  the  vessels  of  the 
choroid.  But  he  distinctly  states:  "In  not  a  single  case  where  it  was  pos- 
sible to  make  an  opthalmoscopic  examination  after  an  extraction  could 
changes  be  found  in  the  arterial  vessels  of  the  retina."  He  further  points 
out  the  fact  that  if  this  were  the  case,  the  functions  of  the  eye  would  suffer 
more  frequently  than  is  the  case. 

In  order  that  this  examination  should  be  conducted  in  the  most  per- 
fect and  reliable  manner,  I  begged  of  Prof.  Adolf  Weil  to  conduct  the 
same.  He  was  kind  enough  to  do  this  with  the  greatest  conscientiousness, 
and  has  permitted  me  to  publish  the  results,  together  with  his  views  on  the 
subject. 

•'Michel's  ideas  have  awaliened  a  number  of  priori  thoughts.  In  the  first 
place,  it  is  difficult  to  understand  how,  with  the  existing  anastomosis  between 
the  two  carotids  and  the  vertebral  arteries,  an  atheromatous  change  in  one  car- 
otid artery,  the  vessels  of  the  eye  itself  being  normal— and  such  he  expressly 
states  to  be  the  case— could  bring  about  disturbance  in  the  lens.  It  is  also 
remarkable  that  though  he  continually  speaks  of  a  connection  between  cloudi- 
ness of  the  lens  and  sclerosis  of  the  carotid,  he  fails  to  state  whether  he  has 
reference  to  the  common  carotid,  the  internal  or  external.  The  internal  carotid, 
even  in  thin  people,  is  not  accessible  to  palpation;  hence,  we  must  assume  that 
his  remarks  refer  to  the  carotis  communis,  or  the  external.  The  relative  fre- 
quency of  atheroma  in  young  people,  the  isolated,  more  especially  the  involve- 
ment of  the  carotid,  the  occurrence  of  arteriosclerosis  on  one  side,  the  absence 
of  all  other  symptoms  which  would  point  to  atheroma  of  the  carotid  in  which 
we  find  true  aneurysmal  formation.  It  is,  however,  as  unknown  for  an  aneu- 
rism of  the  carotid  to  bring  on  a  cataract.  Notwithstanding  these  objections, 
it  nevertheless  seemed  proper  to  determine  by  renewed  investigation  whether 
these  two  conditions  really  existed  at  the  same  time,  though  no  direct  connection 
between  the  two  could  be  proven.  For  this  purpose  the  circulatory  system  of 
fifty-three  cataract  patients  was  examined,  without  the  examiner  knowing  any- 


29  0pthalmish  Beobachtungen.   Berlin,  1867. 


239 
thing  concerning  the  special  condition  of  the  cataract.  (As  to  wiiich  side  the 
cataract  was  confined,  whether  it  was  on  one  or  botii  sides,  etc.)  Examination 
was  made  of  the  heart,  the  brachial  and  the  radial  arteries,  and  the  portion  of 
the  carotis  communis  and  externa  which  were  accessible  to  palpitation,  to  de- 
termine whetlier  the  carotids  were  atlieromatous  or  not.  This  palpitation,  how- 
ever, is  much  more  difficult  than  in  the  case  of  the  radial  or  brachial  arteries, 
which  can  be  more  easily  encompassed  and  compressed.  Judgment  as  to 
whether  the  carotid  is  more  or  less  tortuous,  or  whetlier  the  pulsations  are 
more  marked,  must  surely  be  more  uncertain,  unless  the  degree  of  change  is 
very  great  or  unless  comparison  between  the  right  and  left  offers  a  very  great 
difference.  It  must,  however,  not  be  forgotten  that  even  under  normal  circum- 
stances the  right  carotid  communis  is  often  thicker  than  the  left.  And  a  moder- 
ate dilation  of  the  upper  end  of  the  common  carotid— a  sort  of  bulb— according 
to  the  general  opinion  of  anatomists  must  not  be  looked  upon  as  pathological. 
Every  experienced  examiner  will  agree  with  me  when  I  state  that  the  width 
and  the  tension  in  the  arterial  tube,  as  well  as  the  height  of  the  pulse  wave, 
not  only  in  different  individuals,  but  even  in  the  same  individual,  varies  greatly 
at  different  times.  Hence,  one  will  only  be  able  to  diagnose  with  certainty 
changes  in  the  walls  of  the  arteries  (thickening  and  rigidity),  when  the  anom- 
alie  of  width  and  tension  of  the  arterial  tube,  as  well  as  the  pulse  wave,  ex- 
ceed a  certain  degree." 

The  following  table  gives  the  results  of  Weil's  Examinations: 


Atheroma  of  the 

Atheroma  of  the 

it 

Carotid  without 

Carotid  with 

Heart 

td 

Heart  Disease. 

Heart  Disease. 

< 

Disease 

u 

< 

< 

^E 

=  ^ 

without 

Age. 

0  z 

On  the  side 

Not  on  the 

On  the  side 

Not  on  the 

SS 

Athero- 

ft, 

:- 

^8 

of  the  first 

side  of  the 

of  the  first 

side  of  the 

^5 

ma  OF  the 

diseased 

first  dis- 

diseased 

first  dis- 

Carotid. 

lens. 

eased  lens. 

lens. 

eased  lens. 

1-10 

1* 

2* 

3 

3 

11-20 

2 

2 

•2 

21-30 

1* 

1* 

2 

2 

31-40 

1 

1 

1 

41-50 

2 

3 

5 

3 

1 

1 

51-60 

6 

8 

14 

11 

2 

1 

Hl-70 

8 

9 

17 

8 

2 

4 

1 

2 

71-81 

1 

7 

8 

2 

2 

1 

1 

2 

81-90 

1 

1 

1 

Total... 

22 

31 

53 

32 

6 

7 

2 

1 

5 

1.  The  asterisk  marks  the  four  cataracts  which  occurred  only  on  one  eye. 

2.  Both  of  the  boys'  eyes  eleven  and  twenty  years,  had  zonular  cataract. 

3.  The  man  of  thirty-eight  had  albuminuria. 

4.  Of  the  five  patients  between  forty  and  fifty  years,  three  had  nuclear  cata- 
ract (Becker),  one  had  albumen  in  the  urine.  One  was  a  rapidly  developing 
tumescent  cortical  cataract,  without  the  presence  of  sugar  in  albumen. 


240 

"Hence,  in  but  sixteen  cases  was  there  any  disease  of  the  carotid  to  be 
found,  whereas  in  thirty-seven  cases  this  was  not  the  case.  Of  the  sixteen, 
but  six  had  atheroma  on  the  side  of  the  lens  which  first  became  cloudy;  in 
ten  this  was  not  the  case.  This,  however,  only  occurred  in  individuals 
who  had  passed  the  fortieth  year.  In  the  four  cases  with  cataract  on  one 
eye,  the  condition  of  the  circulatory  apparatus,  especially  of  the  carotid, 
was  found  to  be  normal.  It  would  hardly  seem  necessary  to  examine  into 
this  table  any  further.  This  much,  however,  must  be  patent  to  every 
unbiased  reader;  namely,  that  both  Michel  and  Mooren  have  gone  too  far. 
in  that  the  former  assures  us  that  there  is  an  aetiological  connection  be- 
tween the  so-called  senile  cataract  and  the  one-sided  cataract  of  unknown 
aetiology,  and  that  atheroma  of  the  carotid  offers  a  satisfactory  explanation 
for  this  cloudiness  of  the  lens,  and  the  latter  in  giving  assent  to  the  utter- 
ance." 

"Hence,  I  find  myself  placed  in  the  peculiar  position  of  defending  my 
position  against  Mooren  by  Mooren's  own  statements  made  many  years  ago, 
and  in  which  he  expressed  the  correct  views  concerning  the  aetiology  of 
cataract  (1867)." 

"In  the  above  I  have  given  my  reasons  which  prevent  me  from  accept- 
ing the  views  of  Deutschman  and  Michel  concerning  the  genesis  of  certain 
forms  of  cataract.  There  is  possibly  some  basis  of  truth  in  both,  for  chronic 
nephritis  is  frequently  accompanied  by  disease  of  the  smaller  blood-vessels 
and  capillaries.  According  to  some  authorities  this  disease  of  the  blood 
vessels  is  the  cause  of  the  nephritis.  Likewise,  even  though  Michel  can 
not  convince  himself  of  the  fact,  we  may  assume  that  w^here  there  is  ather- 
oma of  the  carotid  there  is  likewise  disease  of  the  smaller  arteries,  especiallv 
the  smaller  branches  of  the  opthalmic.  This  pathological  condition  of  the 
vessels  of  the  uvea  would  then  offer  us  the  intermediate  link  in  the  chain 
between  cloudiness  of  the  lens  on  the  one  hand,  and  nephritis'  and  atheroma 
of  the  carotid  on  the  other.  As  I  have  already  shown,  both  diseases  may 
then  be  utilized  to  explain  the  occurrence  of  cataract  even  on  the  one  eye, 
if  statistics  made  on  a  large  scale  once  demonstrate  the  more  frequent 
occurence  of  either  two.  And  here  it  is  proper  to  point  out  the  important 
fact,  that  in  the  microscopical  examination  of  cataractous  eyes  more  atten- 
tion might  be  given  to  the  condition  of  tlio  choroidal  vessels." 

In  his  Pathology  and  Therapy  (Sec.  G7,  p.  261)  Becker  draws  attention  to 
some  interesting  points  concerning  the  aetiology  of  senile  cataracts.  He  quotes 
Walter  and  Arlt,  who  claim  that  eyes  with  a  blue  iris  are  more  frequently  af- 
fected than  those  with  a  brown  iris,  for,  says  Arlt:  "the  pigment  in  the  iris 
prevents  the  lens  from  being  acted  on  to  sO  great  a  degree  by  the  light.'"  Though 
Yager,  Arlt.  and  llasner  conclude  that  more  men  are  affected  than  women,  in 


241 

proportion  of  4.3,  Beekor  .oiicliKlfs  that  ilioujili  this  iii;i.v  appiirciiil.v  he  ;i  I'.ict, 
lie  govs  on  1o  state:  "Mmiiv  of  iIm-  ii;iii«'nts  taken  np  in  clinics  come  a  long 
distance  to  be  operati'd.  Tlic  most  ol  tliese  are  poor  people,  so  that  the  ex- 
penses of  such  a  journey  are  met  under  great  difficulties.  Hence,  since  vision  to 
n)an  is  of  greater  valtie  tlian  to  won)an.  since  lie  must  carry  on  his  o<-cupation. 
in  order  to  earn  money  to  supply  the  necessities  of  life;  hence,  this  fact  alone 
will  exi»lain  why  it  is  that  more  men  are  operated  than  women. 

It  has  already  heen  stated  that  cataract  occurs  with  greatest  frequency 
in  the  young  and  in  the  aged,  and  it  is  worthy  of  note  that  after  the  seventieth 
year  there  is  a  very  marked  decrease  in  the  proportion  of  frequency.  In  882 
cataracts  occurring  between  25  and  85  years.  626  occurred  between  45  and  70 
years  (Arlt).  The  majority  of  senile  cataracts  occurred  between  the  50th  and 
70th  year. 

Station  and  occupation  do  not  appear  to  exert  much  of  an  influence.  Cata- 
ract has  been  observed  in  the  English  royal  family.  It  is  probable  that  King 
Wenzel  of  Bohemia  had  a  cataract.  King  Don  Juan  of  Aragon  was  operated  by 
Rabbi  Akiabar.  of  Lerida,  for  cataract  in  146829a  Gladstone,  the  great  English 
Premier,  was  successfidly  operated  in  1895  by  Nettleship.  But  if  senile  cataract 
occurs  but  seldom  among  the  rich  and  notable,  this  may  be  explained  by  the 
fact  that  this  class  forms  but  a  small  percentage  of  the  entire  population. 

Dr.  Meyerhoefer30  draws  attention  to  the  fact  that  cataract  develops  in 
glass  makers.  In  an  examination  of  5(X)  persons  he  found  opacities  in  the 
lenses  of  59,  and  4  had  total  cataract.  This  he  attributes  to  the  excessive  heat 
of  the  oven,  and  the  exceedingly  profuse  perspiration,  which  withdi-aws  large 
quantities  of  fluid  from  the  body. 

The  subject  of  heredity  had  already  been  touched  upon.  A  long  list  of  ob- 
servers could  be  mentioned  who  have  recorded  cases  proving  that  heredity 
plays  an  important  role.  Among  these  we  find  the  names  of  Beer,  Richter, 
Arlt,  Dupuytren,  Sanson.  Streatfield,  Susardi,  Dyer,  Roux,  Maunoir.  Sichel, 
Ullmann,  Bartard,  Hirschberg,  Armaignac.  Galezowski  and  others.  Carreas  y 
Argo  31  has  given  us  a  complete  review  of  this  subject,  and  concludes,  that  the 
liereditary  cataracts  by  preference  attack  individuals  belonging  to  the  same 
sex,  as  the  one  so  first  affected;  further,  that  the  cataracts  do  not  always,  as 
many  authorities  contend,  develop  at  the  same  time  of  life  as  in  the  previous 
generation,  but  quite  the  contrary  at  an  earlier  date,  and  may  even  develop  at 
birth.  Galeowski  places  the  hereditary  percentage  at  from  four  to  tive  per  cent. 
It  is  also  noteworthy  that  the  heredity  is  not  always  continuous;  it  may  skip 
a  generation. 

Galeowski,32  in  the  course  of  nineteen  years  among  128.000  patients,  noted 


29a  I'llersperger  A.  F.  ().,  2,  p.  272. 

30  Zur  Aetiologie  des    (Jrauen    Staares  .Tugendliclier  Iiidividuen    bei    Glass 
macher.    Zehender's  Monatsblatt,  1880. 

31  Hirschberg's  Centralblatt.  August,  1884.  p.  406.    -Von  der  Erblichen  Cata- 
racten  und  ihrer  Ubertragung  auf  Individuen  des  gleichen  Geschlectes." 

32  De  la  marche  el  du  prog  des  Cataract.  Reciveil  d'Opth,  May,  1885. 


242 

4.77G  cataracts  (1,646  senile,  199  traumatic,  1,680  cortical,  231  congenital.  130 
capsular,  94  diabetic.  128  choroidal).  He  ascribes  the  principal  aetiological  fac- 
tors, aside  from  trauma,  to  heridity,  gout,  age  and  the  various  diseases  of  the 
choroid. 

G. 

CATAEACTA  HYPEEMATURA. 

Subsequent  to  the  stage  of  ripeness  of  senile  cataract,  one  of  two  dia- 
metrically opposite  changes  may  take  place.  Either  as  a  result  of  the 
giving  off  of  water  the  cataractous  mass  may  become  smaller  and  inspisated 
— cataracta  liypermatura  reduda — or  the  cloudy  substance  becomes  fluid 
and  the  nucleus  sinks  to  the  bottom  of  the  sac,  during  which  process  chol- 
estearin,  and  possibly  fat,  are  formed,  without  great  development  of  drusen, 
capsular  cataract,  cataracta  Morgagniana. 

1.  CATAEACTA  HYPEEMATUEA  EEDUCTA. 

It  appears  that  in  a  large  number  of  cataracts  which  have  passed  the 
stage  or  ripeness,  the  giving  off  of  water  continues,  and  the  inspisated  cat- 
aractous mass  consists  of  degenerated  lens  fibres.  The  cataract  has  the 
appearance  of  a  drop  of  dried  carpenter's  glue,  and  though  the  radiating 
striations  do  not  entirely  disappear,  these  are  now  associated  with  a  number 
of  quite  regularly  arranged  transverse  striations.  When  the  pupil  is  di- 
lated the  appearance  is  very  similar  to  that  of  a  spiderweb.  About  this 
time  the  cortical  substance,  and  with  it  the  entire  cataract,  may  again  be- 
come transparent.  We  may  assume  this,  since  at  times  patients  who  are 
waiting  for  the  second  eye  to  become  blind  before  coming  for  operation, 
observe  that  they  are  again  beginning  to  see  something  with  the  first  af- 
fected eye  (Arlt  1,  c.  p.  260.)  The  lens  may  remain  in  this  condition  for 
years.  In  course  of  time,  however,  a  capsular  cataracta  develops.  These 
are  the  cases  of  true  phako  scleroma. 

As  far  as  microscopical  examination  goes  this  has  shown  the  presence 
of  fatty  drops,  so-called  myeUn,  cholestearin  plaques,  calcareous  granules 
and  pieces  of  lens  fibres. 

2.  CATAEACTA  HYPEEMATUEA  FLUIDA. 

C  ATE  ACT  A  MOEGAGNIAXA. 

In  another  series  of  cases  we  find  that  though  the  volume  of  the 
tumescent  cataract  is  reduced  below  that  of  the  normal  volume  of  a  senile 
lens,  it  does  not  become  inspisated,  but  becomes  even  more  fluid  than  it 
was  during  the  stage  of  tumescence.  Under  these  conditions  it  becomes 
exceedingly  difficult,  and  in.  some  cases  it  is  impossible,  to  get  anything 


243 
like  a  distinct  reflex  of  the  nucleus  on  focal  illumination.  The  cataract 
has  a  greyish  yellow  color,  and  one  can  no  longer  detect  any  striations.  A 
different  picture  can  be  produced  by  having  the  patient  bend  his  head  for- 
ward for  a  time.  After  a  time  one  will  then  be  enabled  to  observe  a  brown- 
ish, more  or  less  circular  disc,  which  will  disappear  if  he  bends  his  head 
backward.  These  changes  are  due  to  the  fact  that  the  nucleus  is  floating 
in  a  fluid  cataractous  mass,  and  hence  can.  change  its  position.  Being 
specifically  heavier,  it  sinks  to  the  floor  when  the  head  is  in  the  upright 
position,  and  changes  its  position  with  the  relative  position  of  the  head. 
Such  nuclei  have  a  very  similar  likeness  to  a  lentil,  are  perfectly  smooth 
and  transparent. 

Pathologie  and  Therapie,  Sec.  68.  p.  204.  H.  Mullcr  (1.  c,  p.  263)  had  the 
opportunity  of  making  an  anatomical  e-xamination.  He  says:  "On  opening  the 
capsule,  a  thin,  yellowish  pus-like  fluid  escaped,  which  seemed  to  contain  only 
very  delicate  pale  molecules.  A  dense  cloudiness  followed  the  addition  of  acetic 
acid,  and  in  excess  this  cloudiness  again  disappeared,  a  few  flakes  remaining. 
Under  the  microscope  this  pasty  fluid  was  found  to  contain  myelin,  fat  and 
cholestearin. 

Page  265.  I  have  not  been  able  to  positively  determine  the  name  of  him, 
or  for  which  particular  variety  the  name  C.  Morgaoniana  was  first  used.  Mor- 
gagni  (1.  c,  Epis.  63,  6)  described  a  case  which  may  have  led  to  the  use  of  this 
name.  He  gives  the  following  description  of  the  eye  of  a  man  40  years  of  age 
who  in  youth  had  had  smallpox,  and  who  acquired  a  corneal  cicatrix,  in  con- 
sequence of  which  he  was  nearly  blind.  "Scleroticam  igitur  cuma  tergo  vix 
incidere  coepissem:  limpida  aqua  statim  effluxit,  it  quam  pass  magna  vitrei 
humoris  videri  poterat  al)iisse,  cum  pass  reliqua,  natural!  quadantenus  similis, 
annexa,  ut  solet,  crystallino  humori  restitisset  qui  illam  cum  retrosum  traherem, 
secutus  est.  Is  parvus  erat  secundum  om  nes  dimensioues.  crassit  autem 
vel  paulo  minor  quam  ejusmodi  oculo  conveniret.  Facie  anteriore  in  medio 
cral  albus,  siucti  per  corneam  transpexeram,  caetera  albidus;  et  cum  inter  digi- 
tos  leviter  comprimerem,  mollis.  Cumvero  ejus  tunican  incidere  coeppisem; 
continuo  apua  erupit.  nihil  purulenti  habens,  imo  pura,  el  limpida,  eague  copia 
pro  parvitate  crystallini.  ut  hie  statim  ad  multo  minorem  crassitudinem  redig- 
eretur.  Quidquid  de  substantia  ipsius  reliqum  fuit.  lentls  pristinam  figuram  re- 
tinuit;  el  cum  per  diametrum  disse  cuissem;  utraque  sectio  quandam  quasi 
seriem  mimarum  nigrescentiam  particularum  ostendit.  quae  per  medium  recta 
ab  uno  ad  alterum  sectionio  ducelxatur.  cum  ubrique  alibi  color  absolete  albidus 
appareret." 

Aside  from  the  fact  that  this  is  the  first  report  of  a  case  of  detachment  of 
the  vitreous,  one  could  call  this  a  case  of  cataracta  Morgagnia,  as  we  understand 
it  today.  Here  we  find  a  capsular  cataract,  a  fluid  corticalis,  and  within  a 
regularly  floating  nucleus.  In  one  point  only  does  it  not  tally:  the  fluid  which 
escaped  was  clear  not  cloudy.    I  could  find  no  reference  to  this  case  by  authors 


244 

whicli  would  tend  to  show  that  they  based  their  writings  on  tlie  above  case. 
Jamin  (1.  c,  p.  243  and  264)  describes  two  cases,  in  one  of  which  the  nucleus 
was  found  floating  in  a  milkj'  cortical  substance,  the  nucleus  being  a  regular 
brown,  the  other  showed  a  greyish  blue,  slimy  corticalis.  after  the  evacuation 
of  which  a  perfectly  transparent  nucleus  remained,  by  means  of  which  tlie 
patient  is  said  to  have  been  able  to  read  and  see  small  objects  without  the  use 
of  glasses.  In  a  foot  note,  speaking  of  the  first  ease,  Jamin  says  (1.  c,  p.  244) 
that  the  cloudy  fluid  was  simply  altered  humor  Morgagni.  and  that  in  the  sec- 
ond case  the  humor  Morgagni  was  simply  cloudy.  The  statements  of  Morgagni 
in  reference  to  this  matter  are  found  in  his  "Adversaria  Anatomica  Sexta  Anima 
Adversa,  LXXI,"  and  reads  as  follows:  "Deinde  eadem  tunicam  in  vitulis 
etiam.  bobus(iue  sive  recens,  sive  non  ita  recens,  occisis  perforata 
plures  auimadverti  illico  humorem  (|uendam  aqiieum  prodire;  quodet  et  in 
homine  observare  visus  sum."  Himly  (1.  c,  p.  229)  bases  his  statements  on 
the  writings  of  Jamin,  and  is  of  the  opinion  that  Morgagni  was  the  first  to 
differentiate  between  Morgagni*s  cataract  and  milk  cataract,  and  also  accepts 
the  name  for  the  second  condition.  Beer  (1.  c,  p.  292)  likewise  uses  the  one 
name  for  both  varieties.  Notwithstanding  this  I  would  have  doubted  the  exist- 
ence of  such  a  condition  had  not  Arlt  (1.  c,  II.  p.  257)  described  a  case  belong- 
ing to  this  variety.  Owing  to  its  rarity  I  will  give  an  abbreviated  quotation. 
A  girl  9  years  of  age  had  cataract  on  both  eyes,  and  these  had  developed  six 
to  eight  weeks  subsequent  to  birth.  The  cataracts,  which  were  yellowish  grey 
in  color,  with  here  and  there  greyish  opacities,  were  about  1  mm.  removed 
from  the  iris,  and  the  patient  saw  sufficiently  to  get  about.  On  dilating  the 
pupils  a  milky  fluid  was  disclosed  in  both  capsules  surrounding  both  nuclei,  not 
unlike  a  hypopyon.  The  nuclei  changed  their  position  with  every  movement 
of  the  head.  For  two  years  the  amount  of  vision  remained  unchanged.  In  the 
eleventh  year  the  discission  was  made.  After  incision  of  the  capsule  a  quantity 
of  cloudy  fluid  escaped,  and  the  pupils  appeared  black.  The  child  could  now 
recognize  the  fingers  of  the  hand,  a  handkerchief,  etc.  On  the  twelfth  day  a 
decided  reaction  set  in— hydro  meningitis.  The  lens  gradually  became  cloudier 
and  more  voluminous,  and  after  three  months  was  totally  resolved.  Arlt  spe- 
cifically designated  this  as  a  cataract  Morgagni,  though  his  description  is  ex- 
actly that  of  a  cataract  Morgagni.  as  we  have  described  it  in  the  aged.  All  the 
late  authorities  use  the  name  only  for  those  cases  where  the  cortical  substance 
becomes  fluid  in  advanced  life,  and  the  hard  nucleus  sinks  to  the  bottom  of  the 
sac.  If  we  wish  to  do  justice  to  both  varieties,  one  is  compelled  to  include 
under  the  name  cataract  Morgagni  all  those  ca.ses  in  which  the  cortex  is  fluid 
and  the  nucleus  hard,  aside  from  the  color  of  the  nucleus,  which  in  age  is 
sclerosed,  whereas  in  youth  this  is  soft  and  transparent. 

A  later  examination  is  by  Knies,  (p.  182),  wlio  examined  a  case  in 
which  Horner  had  made  the  extraction;  the  case  of  a  woman  forty-three 
years  of  age.  "The  entire -anterior  capsular  epithelium  was  normal:  in  tV.e 
equatorial  region  there  was  an  excessive  prnlifcralioii  and  many  of  the  well- 


245 
known  large,  romul  vesicles,  partly  eonlainiiig  nuelei.  other  new  formations, 
sueli  as  we  are  accustomed  to  find  in  the  so-called  crystalline  pearls.  As  yet 
we  can  not  state  whether  we  are  to  seek  the  cause  of  the  Morgagni's  cata- 
ract in  a  perverted  crystalline  pearl  formation  in  which  the  epithelial  cells 
have  undergone  a  mucoid  or  si  miliar  change.  "The  nucleus  shows  no 
change  different  from  that  observed  in  other  cataxacts;  the  fluid  between 
it  and  the  capsule  was  coagulated  by  the  hardening  fluid,  (alcohol  and  Mul- 
lers  fluid)  ,and  consisted  largely  of  myelin  globules  and  detritus,  in  which 
nothing  special  could  he  recognized." 

If  we  will  designate  every  cataract  in  which  the  cortical  substance  has 
become  fluid  as  a  catarada  Moryagtiiana,  we  will  meet  with  it  at  every 
period  of  life,  even  congenitally.  Only,  the  fluid  cataracts  of  youthful  in- 
dividuals do  not  possess  a  nucleus.  However,  in  these  cases  one  frequently 
finds  present  in  the  fluid  an  unusually  large  quantity  of  carcareous,  finely 
granular  matter,  and  crystals.  If  the  eye  is  kept  perfectly  quiet  for  a  time 
the  calcareous  matter  gravitates  to  the  bottom;  whereas  above,  there  will 
be,  relatively  speaking,  a  clear  fluid.  If  the  eye  is  moved  about,  the  cataract 
assumes  a  milky  hue.  In  the  few  cases  of  catarada  ladea  examined,  just 
as  in  the  firm  cataracta  calearea,  the  epithelium  of  the  anterior  capsule  was 
found  practically  destroyed. 

In  older  individuals  one  always  finds  a  nucleus  in  the  fluid  cortical 
substance.  The  volume  of  the  nucleus  depends  on  the  age  of  the  indi- 
vidual; the  younger  the  individual,  the  smaller  the  nucleus.  N'evertheless, 
the  age  of  the  cataract  must  be  taken  into  consideration  as  a  factor;  for  at 
times  one  does  flnd  a  very  small  nucleus  in  old  people;  so  that  one  must 
assume  that  the  decrease  in  the  volume  of  the  nucleus  is  the  result  of 
maceration  in  the  fluid  corticalis.  The  smallest  nucleus  Becker  extracted 
Avas  obtained  from  a  man  fifty-seven  years,  and  it  weighed  in  its  fresh  state 
0.07  grm.  The  normal  weight  of  a  lens  of  the  same  age  is  0.24  grni.,  and 
the  weight  of  a  large  nucleus  of  a  mature  cataract  about  0.13  grm.,  so  that 
the  supposed  melting  away  of  the  nucleus  must  have  equaled  about  one- 
half  in  its  weight. 

I  have  frequently  examined  the  coi-tical  mass,  and  have  always  found 
cholesterine  and  fat. 

THE  CONDITION  OF  THE  INTKACAPSULAR  CELLS  IN  OVER- 
RIPE CATARACTS. 

Almost  without  exception,  in  cases  of  catarada  hypermattira  reduda; 
less  frequently  in  cases  of  cataracta  Mon/agniaua  which  have  existed  for 
any  length  of  time,  we  find  capsular  cataracts  developing.     All  the  various 


246 

stages  \vhieh  have  been  described  in  the  earlier  part  of  this  work  are  met 

uath  here. 

I  desire,  however,  to  draw  attention  to  a  point  in  the  genesis 
of  capsular  cataract,  which  was  probably  not  sutficiently  dwelt  upon. 
If  after  the  volume  of  the  lens  is  reduced;  during  the  time  of  prep- 
aration for  the  cataract  formation  is  going  on,  and  the  epithelial  cells, 
which  have  not  lost  their  formative  power,  are  incited  to  reproduction;  the 
question  might  be  asked,  why  it  is,  that  the  former  method  of  formation  of 
lens  fibres  at  the  whorl  does  not  continue  and  proceed  to  the  laying  dawn 
of  new  lens  fibres  and  lamellae.  Undoubtedly  the  epithelium  must  have 
undergone  a  change  ivhich  prevents  this.  A  normal  increase  is  only  pos- 
sible where  the  formation  of  new  cells  is  distributed  over  the  entire  epi- 
thelial surface  and  where,  as  a  result  of  indirect  nuclear  division,  the  new 
cells  force  themselves  in  between  the  old,  and  thus  cause  a  gradual  move- 
ment toward  the  equator.  If  we  will  now  assume  that  this  power  to  move 
along  the  inner  surface  of  the  capsule  is  lost  to  the  cells,  which  have  fallen 
a  prey  to  the  simple  senile  atrophy;  hence  the  new-fonned  cells  will  like- 
wise be  retarded  in  this  power  of  locomotion,  and  will  form,  at  the  place 
where  they  are  developed,  heaps  of  cells  which  in  the  further  course  of 
changes,  gradually  go  over  to  form  a  capsular  cataract.  This  loss  of  power 
of  locomotion  hence  becomes  an  essential  factor  in  the  formation  of  a  capsular 
cataract.  This  assumption  is  supported  by  the  fact,  that  along  the  posterior 
capsule,  where  the  hindrance  does  not  exist,  one  so  frequently  finds  a  com- 
plete epithelial  covering  developing  from  the  cells  along  the  equator. 

As  Knies  and  Muller  have  stated,  in  Morgagni's  cataract  one  fre- 
quently finds  the  epithelium  as  well  preserved  as  in  other  unripe  cataracts. 
In  all  the  cases  which  I  examined,  as  well  as  in  the  cases  of  Kniess  and 
Muller,  the  vesicular  cells  in  the  equatorial  region  were  excessively  devel- 
oped. It  appears  that,  whereas  Knies  observed  their  development  ex- 
clusively in  the  equatorial  region  of  the  lens,  Muller  claims  to  have  seen 
them  develop  in  different  ways,  as  did  Wedl,  from  other  epithelial  hyper- 
plasias and  formations  along  the  posterior  capsule. 

These  vesicular  formations  are  a  constant  production  in  all  cataract 
formations.  Knies  was  the  first  who  gave  utterance  to,  or  more 
properly  speaking,  recorded  in  literature,  this  thought,  which  is  worthy 
of  respect.  Notwithstanding  our  total  ignorance  as  to  the  cause,  why  it 
is  that  in  one  case  the  corticalis  of  over-ripe  cataract  becomes  inspisated; 
in  another,  notwithstanding  the  giving  off  of  fluid,  it  becomes  fluid;  I  can 
not  refrain  from  expressing  the  thought,  as  to  whether  it  is  not  possible 
in  cases  where  we  find  such  excessive  formation  of  vesicular  cells,  for  these 
later  on  "to  flow  together,"  and  thus  form  the  anatomical  basis  for  a  Mor- 
gagni's  cataract. 


247 

CATARACTA  NIGRA. 

"The  name  of  this  form  of  cataract,  as  well  as  its  existence,  has  been 
both  variously  applied  and  understood.  Wenzel  (1.  c,  p.  38)  describes  the 
extraction  of  a  lens  taken  from  an  eye  in  which  vision  was  very  much  re- 
duced, the  pupil  of  which  did  not  appear  grey;  so  the  existence  of  the  cat- 
aract was  doubted.  A  large  dark-brown  lens  escaped  from  the  wound.  The 
wound  healed,  and  vision  was  restored.  This  form  of  cataract  he  called 
catarada  nigra.  The  entire  description  showed  that  he  was  dealing  with 
a  lens  in  which  the  formation  of  the  nucleus  extended  up  to  the  capsule 
without  the  process  ever  having  come  to  a  standstill.  Such  exquisite  ex- 
amples, in  which  no  cortex  remains,,  are  but  seldom  encountered.  They 
might  also  be  called  catarada  hrunescens." 

"It  would  be  proper  to  translate  catarada  nigra  as  the  'black  grey  cataract,' 
but  not  as  "black  cataract,"  since  this  latter  term,  even  today,  is  used  to  define 
absolute  amaurosis.  It  is  interesting  to  note  that  in  former  times  both  the 
English  and  the  French  used  the  expression  cataracta  nigra  synonymously 
with  gutta  serena  and  paralysis  (?)  of  the  optic  nerve.  I  find  it  is  so  used  by 
Pereival  Pott;33  also  by  Morgagni.34  in  a  dissertation  by  Von  Warnatz  (Cata- 
racta Nigra,  1832)  is  found  a  very  complete  compilation  of  the  literature  on  this 
subject.  In  later  times  Von  Graefe  35  accepts  the  name  of  cataracta  nigra  for 
those  cataracts  in  which  pigment  is  found  inside  the  capsule,  which  he  consid- 
ers as  coming  from  the  haematin  which  has  passed  through  an  uninjured  cap- 
sule. Cases  belonging  to  this  class  have  also  been  described  by  Von  Beck. 
Should  it  become  an  established  fact  that  pigment  does  pass  through  the  cap- 
sule, it  certainly  would  be  proper  to  call  these  cataracta  pigmentaire,  or  cata- 
racta hemorrhagica,  rather  than  cataracta  nigra.  I  can  not  understand  how  men 
can  be  such  blind  followers  of  Von  Graefe  as  to  persist  in  writing  about  the 
frequent  occurrence  of  cataracts  containing  haematin." 

Since  it  has  been  shown  that  the  nucleus  of  a  senile  cataractous  lens 
differs  chemically  from  the  simple  sclerosis  of  old  age,  the  cataracta  nigra 
must  be  looked  upon  as  a  senile  cataract,  which,  in  consequence  of  the 
regularly  progressing  sclerosis  up  to  the  periphery,  is  not  accompanied 
by  the  formation  of  splits  and  fissures,  in  the  most  peripheric  cortical 
lamellae. 

The  most  essential  points  in  the  senile  sclerosis,  as  well  as  in  the  senen- 
scence  of  the  lens  are  the  following;  the  oldest  fibres  in  the  centre  of  the  lens 
lose  the  serrations  which  they  had  attained  during  the  growth  of  the  entire 

33  Remarques  sur  la  Cataracte,  Traduit  de  la  Auglaisse  par  Lemoine,  1779, 
p.  501. 

34  Epist.,  XIII.  13.  14.    17(;2. 

35  Arch.,  I.  p.  1.33. 


248 

organism,  and  with  tlie  steady  increase  in  the  index  of  refraction  and  tlie 
taking  on  of  a  more  saturated  yellow  color,  until  finally  an  almost  homo- 
genous mass  is  formed,  in  which  the  individual  elements  are  scarcely  recog- 
nizable, or  not  at  all;  and.  as  age  advances,  this  process  slowly,  but  surely, 
extends  toward  the  periphery.  At  the  same  time,  the  processes  at  the  whorl 
and  along  the  nuclear  zone  become  less  active  and  consist  of  but  few  ele- 
ments containing  nuclei.  The  epithelial  cells  become  fat,  and  in  many 
the  chromatic  substance  and  the  nuclei  are  greatly  reduced.  The  capsule 
becomes  thicker  and  tougher.  The  farther  this  process  extends,  the  more 
light  will  be  absorbed,  and  the  poorer  will  the  vision  be.  where  there  is  a 
moderate  degree  of  illumination.  This  explains  one  of  the  causes  for  the 
reduction  of  vision  in  the  aged." 

"It  may,  however,  happen  that,  even  in  very  advanced  age,  not  even  an 
equatorial  cloudiness  may  exist — gerontoxon  lentis — and  the  individuals 
have  good  vision.  Thus  I  have  had  the  opportunity  of  examining  the  lens 
of  a  man  ninety-four  years  of  age,  and  on  focal  illumination  found  but  a 
scarcely  recognizable  yellowish  reflex;  whereas,  on  opthalmoscopic  examina- 
tion, the  lens  was  perfectly  clear,  and  with  a  convex  glass  of  3  D  on  both 
eyes,  ^=1%  to  |. 

"Then,  again,  tliere  are  people  who  see  much  more  poorly  at  an  earlier 
age — thus  I  have  examined  people  who,  as  early  as  the  fifties,  could  scarcely 
count  fingers  at  one  or  two  metres;  without  any  cloudiness  of  the  lens  being 
discernable  with  the  mirror;  whereas,  on  focal  illumination,  there  is  a  deep 
brownish-red  reflex  from  the  lens.  Therefore,  this  remarkable  difference 
in  the  conditions  of  the  lens,  noted  during  life,  is  due  to  the  pathological 
sclerosis  and  saturated  color  of  the  nucleus  in  cataracta  nigra. 

I  have  examined  anatomically  two  lenses  extracted  in  their  capsules,  and 
sent  to  me  by  Dr.  Mittelstadt  and  Dr.  Marckwort,  of  Antwerp,  the  diagnosis 
being  cataractae  fere  nigrae.  Very  fine  micj-oscopical  sections,  made  with  the 
microtome,  show  that  the  entire  lens  up  to  the  capsule  are  regularly  changed 
to  nucleus.  The  whirl  and  nuclear  zone  consist  of  but  few  cells.  On  trans- 
verse sections  only  the  nuclei  appear  on  the  inner  surface  of  the  capsule,  the 
protoplasm  of  tlie  cells  l)eing  so  greatly  reduced.  One  finds  no  pictures  of 
splits  or  fissures  in  the  sections.  It  is  especially  worthy  of  note  that  there  is 
not  a  trace  of  cortical  substance  between  capsule  and  nucleus.  The  only  dif- 
ference between  this  lens  and  the  senile  lenses  of  the  same  age  would  be  the 
sparse  and  frequently  interrupted  distribution  of  vesicular  cells  in  the  equa- 
torial region.  Teased  preparations  show  nothing  differing  from  that  formed  in 
normal  lenses.     There  was  no  particular  avidity  to  the  stain. 

About  the  same  conditions  were  found  in  another  lens  received  from  Sam- 
melsohn.     In  the  equatorial  region,  however,  were  large  nests  of  vesicular  cells. 

'J'lierct'drc.  ciitaracla   nigra  is  a  snccial   variety  of  senile  cataract,  but 


249 
differs  froiii  the  o]-(liii;irv  senile  lens  of  the  <;niie  ;i:ie  in  the  patliological 
miclear  sclerosis,  which,  as  we  have  seen  in  the  underlying  basis  in  the  de- 
velopment of  senile  cataract.  TTence,  the  same  reasons  likewise  apply  here, 
which  lead  lis  to  coiisi(h'r  senile  calni'act  as  a  consl  ii  ntional  (;ataracl. 

CATAlfACTA  CAl'STLAinS.     CAFSl'LAi:  CATAKACT. 

As  we  have  seen,  capsular  cataract  is  most  fretjiiently  a  sequelae  of  the 
over-ripe  cataract.  Jf  we  only  waited  long  enough,  we  would  find  that  to 
every  lenticular  cataract  finally  would  be  added  a  capsular  cataract. 

The  variety  generally  observed  by  the  oculist  is  seated  at  the  anterior 
pole.  In  the  non-complicated,  over-ripe  senile  cataract,  it  usually  ac(|uires 
about  the  size  of  a  medium-sized  pupil.  It  then,  as  a  rule,  has  sharply  de- 
fined, jagged  edges,  and  it  is  generally  accepted  that  these  jagged  edges 
mark  the  line  of  insertion  of  the  zonular  fibres  into  the  capsule.  Fre- 
quently the  capsule  is  folded  in  the  portions  which  cover  the  capsular  cat- 
aract, and  in  cases  of  pyramidal  cataract,  this  frequently  reaches  the  height 
of  a  millometre.  These  folds  are  a  proof  that  this  new-formed  tissue  has  a 
tendency  to  shrink,  and  in  this  shrinkage  is  to  be  found  the  reason  for  the 
loosening  of  the  connection  between  the  capsule  and  its  suspensory  liga- 
ment, and  this  may  lead  to  cases  of  spontaneous  luxation  of  over-ripe  cata- 
racts. This  also  makes  possible  the  operation  where  the  lens  is  extracted 
in  its  capsule. 

There  are  many  exceptions  to  the  restriction  of  the  capsular  cataract 
to  the  pupillary  area.  This  is  especially  true  of  the  consecutive  cataracts, 
for  it  may  extend  over  the  entire  inner  surface  of  the  anterior  capsule,  and 
may  even  extend  over  the  posterior  capsule.  It  is  especially  in  these  forms 
of  capsular  cataract  that  we  so  fi-C(iucntly  iind  tiie  calcareous  de- 
posits. The  capsular  cataract  may  remain  unassociated  with  any 
other  form  of  cataract  for  many  years.  When  a  capsular  cataract  de-. 
velops  in  advanced  age,  the  lenticular  cataract  will  soon  follow.  The  pri- 
mary development  of  a  capsular  cataract  is  the  purest  example  of  what 
might  be  technically  designated  as  an  inflammation  of  the  lens,  (or  hyper- 
plasia of  epithelial  cells),  a  true  phakitis;  but  where  this  occurs,  the  eye  is 
otherwise  diseased,  even  though  its  exact  nature  be  indefinite.  The  mere 
presence  of  a  primary  capsular  cataract  should  arouse  our  suspicions  of 
other  complications.  If  Leber's  theory  is  correct,  that  these  epithelial 
cells  have  the  function  of  giving  the  nutritive  fluids  their  specific  chemical 
constitution,  it  certainly  must  be  evident  that  a  diseased  epithelium  must 
of  necessity  finally  be  followed  by  a  lenticular  cataract,  and  likewise  it  must 


250 

not  be  forgotten  that  a  diseased  nutritive  material  (aqueous  or  vitreous) 
can  stimulate  the  capsular  cells  to  proliferation.    , 

True  capsular  cataract  does  not  only  occur  congenitally  as  an  anterior 
polar  cataract,  but  it  may  be  acquired  primarily  at  any  age  of  life. 

CHAPTER  XI. 

TRAUMATIC  CATARACT.  CATARACTA  TRAUMATICA. 

Mechanical  disturbances  may  lead  to  an  injury  of  the  lens,  and  thus 
secondarily  lead  to  the  development  of  traumatic  cataract.  This  may  be 
due  to  the  action  of  a  blunt  force,  as  a  concussion,  or  as  the  result  of  a 
puncture,  accidentally;  or  of  an  incision,  intentionally  produced,  as  where 
discission  is  practiced. 

A. 

CATARACTA  EX  CONTUSIONE.  Here,  as  a  rule,  the  capsule  of 
the  lens  is  ruptured,  and  the  lens  becomes  cloudy,  in  consequence  of  com- 
ing in  contact  with  the  fluid  media  of  the  eye.  In  exceptional  cases  the 
lens  substance  becomes  cloudy,  even  when  the  capsule  has  not  been  rup- 
tured. Thus  Arlt^  states,  "though  we  do  not  as  yet  possess  any  reliable 
reports  of  cases  in  which  a  concussion  of  the  eyeball,  in  which  neither  a 
rupture  of  the  capsule  nor  a  simple  tearing  of  the  capsule  has  taken  place, 
lead  to  a  cloudiness  of  the  lens;  still,  as  a  rule,  we  must  acknowledge  the 
possibility  of  its  occurrence."  The  truth  of  this  statement  seems  to  be 
proven  by  the  fact,  that  Berlin  ^  produced  a  cloudiness  of  the  anterior 
cortical  substance  by  gently  tapping  the  eyes  of  rabbits  with  an  elastic  rod. 
Becker  reports  the  following  case,  in  which,  as  the  result  of  a  con- 
cussion of  the  eyeball,  without  a  tearing  of  either  the  zonula  or  capsule, 
cloudiness  of  the  lens  followed: 

During  the  winter  of  1870-72,  a  policeman,  stationed  at  tlie  railway  tunnel 
running  under  the  Heidelberger  Schloss,  while  engaged  in  removing  large 
icicles  which  had  formed  at  the  entrance  of  the  tunnel,  was  struck  by  one  of 
these  in  his  right  eye.  The  pain  was  not  very  severe,  but  vision  at  once  became 
cloudy.  Several  days  later  he  presentd  himself  at  the  clinic,  and  vision  was 
found  to  equal  ^g.  There  was  no  sign  of  an  external  injury,  luxation  or  tear 
of  the  capsule,  but  we  found  a  rupture  of  the  choroid.  This  latter  was  quite 
centrally  located,  but  not  very  large.  From  time  to  time  he  presented  himself 
at  the  clinic,  so  that  we  had  the  opportunity  of  carefully  observing  the  gradual 
development,  from  the  third  week  on,  of  an  anterior  polar  cortical  cataract, 

lUber  die  Verletzungen  des  Auges  in  Gerichtsartzlicher  Beziegung,  1.  c, 
p.  296. 

2Zur  Sogen  Commotio  Retinae.     Monatsblatt,  1873,  p.  47. 


251 

which  assumed  the  same  form  as  a  posterior  cortical  cataract,  after  an  injury 
of  the  periphery  of  the  lens.  After  it  had  developed  to  about  one-half  the  size 
of  a  medium  dilated  pupil  it  became  stationary.  After  a  year  the  railway  com- 
pany gave  him  an  easier  position,  so  that  he  passed  from  observation. 

Whenever  a  unilateral  cataract  is  met  with  an  indefinite  time  after  a 
contusion  of  the  eye,  one  should  not  forget  that  the  cataract  may  be  the 
result  of  an  injury  to  the  eye  other  than  a  lesion  of  the  capsule  or  zonula. 
It  is  only  of  too  frequent  occurrence  that  months  pass  before  the  lens  be- 
comes cloudy,  and  then  the  cataract  is  to  be  looked  upon  as  consecutive. 
However,  there  must  not  always  be  a  rupture  of  the  choroid;  hemorrhage 
into  the  vitreous,  with  secondary  detachment  of  the  retina;  but  a  con- 
secutive cataract  may  develop,  when  the  only  demonstratable  sign  is  a 
paralysis  of  the  ciliary  body,  together  with  an  apparent  myopia.  Hence, 
great  care  should  be  practiced  in  making  a  prognosis,  even  in  apparently 
slight  contusions  of  the  eyeball,  and  this  should  be  especially  remembered 
as  a  point  in  medical  jurisprudence. 

Euptures  of  the  capsule,  independent  of  a  tear  in  the  coats  of  the  eye- 
ball or  of  the  zonula,  have  been  but  rarely  reported.  Isolated  cases  of  tear- 
ing of  the  posterior  capsule  have  been  reported  by  Knapp  and  Aub.^ 

John  R.,  aged  20  years,  the  son  of  a  farmer  living  at  Kuhbergershof,  while 
chopping  branches  from  a  tree,  was  struck  in  the  eye  by  a  twig.  Vision  at 
once  was  impaired,  without  any  visible  sign  of  injury.  Two  weeks  later,  since 
vision  did  not  improve,  he  was  brought  to  the  clinic.  It  was  impossible  to 
detect  the  slightest  trace  of  an  injury,  either  in  the  lids,  conjunctiva  or  cornea. 
The  conjunctiva  bulbae  was  pale,  and  there  was  absolutely  no  ciliary  injection 
present.  Cloudy  lens  substance  was  being  extended  through  the  narrow  pupil 
into  the  anterior  chamber.  Tension  was  normal.  Field  of  vision  intact,  and 
he  could  count  fingers  at  one  foot.  He  had  no  pain;  there  was  no  irritability 
to  light,  no  increased  secretion  of  tears.  On  use  of  atropine  the  pupil  dilated 
and  disclosed  no  synechia.  Though  the  patient  was  repeatedly  examined  later 
on,  and  notwithstanding  every  possible  effort,  no  trace  of  an  injury,  more  es- 
pecially of  tlie  cornea,  could  be  detected.  And  since  on  dilating  the  pupil  a 
change  of  position  of  the  lens  system  could  be  absolutely  excluded,  hence  the 
diagnosis  of  a  simple  rupture  of  the  capsule  of  the  lens  as  the  result  of  a  con- 
tusion was  justified.  The  progress  of  the  case  was  an  exceptionally  favorable 
one,  and  the  lens  was  totally  resorbed  without  the  occurrence  of  any  com- 
plications. 

B. 

Frequently  a  simultaneous  luxation  takes  place — that  is,  a  tearing  of 
the  zonula  zinii  and  a  rupture  of  the  capsule.  All  these  cases,  in  which  one 
is  able  to  demonstrate  a  subluxation  of  the  lens,  and  to  which  already  in 

3  Arch,  fur  Augen  und  Ohren,  I,  1,  p.  20  and  II,  1,  p.  256. 


252 

the  first  few  days,  a  cloudiness  of  tlie  lens-is  added;  beloii;^  to  tliis  class.  In 
most  of  these  cases  the  lesion  in  the  capsule  is  in  the  equatorial  region  be- 
tween the  insertion  of  the  zonula  and  its  anterior  and  posterior  attach- 
ments. All  clinical  observations  show  that  the  cloudiness  begins  in  the 
tMiuatorial  region. 

c. 

INJURIES  CAUSED  BY  CUTTING  Oil  POINTED  INSTRU- 
MENTS NEARER  aifect  the  lens  alone.  The  symptoms,  the  course  and 
prognosis  depend  entirely  on  the  size  of  the  capsular  wound,  the  depth  to 
which  the  instrument  penetrates  the  lens,  the  kind  and  extent  of  the  in- 
jury, which  at  the  same  time  affects  other  parts  of  the  eye,  and  also  as  to 
whether  the  body  which  causes  the  injury  remains  partially  or  entirely 
within  the  eye.  Should  the  body  which  causes  the  injury  only  penetrate 
the  cornea  and  the  lens,  and  do  no  other  injury,  we  will  have  a  condition 
to  deal  with  similar  to  a  discissio  per  corneam.  If  the  corneal  wound  is  a 
large  one,  some  of  the  lens  substance  may  be  extruded,  and  hence  the  ab- 
sorption hastened,  but  just  such  wounds  later  on  materially  interfere  with 
vision. 

If,  besides  cornea  and  lens,  other  portions  of  the  eye  are  involved — the 
iris,  the  sclera,  and  corpvs  ciliare,  the  vitreous,  etc. — the  prognosis  largely 
depends  on  the  extent  of  the  injuries.  Penetrating  wounds  which  at  first 
appear  trivial,  owing  to  infection,  may  become  the  most  serious. 

Where  the  foreign  body  penetrates  through  the  periphery  of  the  cor- 
nea and  the  ciliary  portion  of  the  iris  into  the  lens,  so  that  the  lens  is  struck 
near  the  equator,  it  very  curiously  indeed  happens  that,  aside  from  the 
cloudiness  in  the  neighl)orhood  of  the  point  of  entrance,  the  posterior  cor- 
tical substance  is  clouded  earlier  than  anywhere  else.  On  dilating  the  pupil, 
it  is  possible  to  follow  the  entire  course  of  the  penetrating  instrument 
through  the  lens,  and  the  same  cloudy  lens  star  develops.  If  the  wound  is 
not  large  it  may  close  again,  and  the  opacity  remain  restricted  to  the  poste- 
rior coriical  substance,  or  eventually  clear  up  again.''  If  small  foreign 
bodies  eulor  the  lens,  they  may  either  still  stick  fast  in  the  cornea  by  the 
other  end.  ])pnetrate  the  iris  or  extend  into  the  pupil  and  anterior  chamber, 
and  be  recognized  l)y  the  naked  eye;  or  they  may  be  entirely  enclosed  in  the 
lens  capsule;  or,  finally,  they  may  pass  througli  the  lens  and  be  found 
sticking  fast  in  the  })osterior  wall  of  tlie  eye,  or  be  found  lying  free  in  the 
vitreous.  As  long  as  the  lens  remains  transparent,  one  can  get  a  view  of 
these  foreign  bodies  by  means  of  the  opthalmoscope. 

The  diagnosis  is  easy,  where  it  is  possible  to  see  tlie  foreign  body  in 

4  Vergl  die  Berichte  der  Wiener  Clinic,  p.  87  and  No.  7G. 


253 
the  cornea  or  iris  alone,  or  in  both,  and  penetrating  the  lens.  That  the 
lens  is  involved  becomes  evident,  owing  to  the  more  or  less  diffuse  cloudi- 
ness which  in  such  cases  is  never  wanting.  It  is  more  difficult  at  times  to 
demonstrate  the  presence  of  a  foreign  body  which  is  entirely  enclosed  in 
lens  substance,  especially  when  the  lens  has  secondarily  become  totally 
cloudy.  It  then  depends  entirely  on  the  color  of  the  foreign  body  whether 
or  not  one  can  still  see  it.  However,  it  is  not  necessary,  nor  does  it  always 
occur,  that  the  entire  lens  becomes  cloudy.  One  then  sees,  either  in  the 
anterior  cortical  substance  a  circumscribed  white  cloudiness,  with  its  cor- 
responding capsular  wound;  or,  if  the  cloudiness  lies  deeper,  we  see  between 
it  and  the  capsule  a  linear  cloudy  path  which  indicates  the  course  of  the 
foreign  body.  If  the  reports  of  some  authors  are  to  be  believed,  we  can 
at  times  recognize  the  foreign  body. 

Many  observers  attest  the  fact,  that  the  capsule  may  close  again  after 
the  entrance  of  a  small  foreign  body,  and  this  be  retained  in  the  lens. 
Especially  where  the  wound  is  in'  the  region  of  the  iris,  this  may  form  a 
primary  object  of  closure.  When  the  wounds  are  in  the  centre  of  the  pupil, 
the  iris  can  be  of  no  assistance,  and  still  it  is  possible  for  the  wound  to 
heal  without  any  lens  substance  ever  having  been  extruded — a  true  sanatio 
per  primam  intentionem.  More  frequently,  the  wound  only  heals  after 
a  flake  of  greater  or  less  size  has  been  extruded  and  been  absorbed.  In  the 
vicinity  of  the  wound  the  capsule  is  always  folded. 

Becker  states  that,  from  his  own  experience,  he  knows  that  grains  of 
powder  may  become  encapsulated  in  the  lens  without  causing  a  total  cloudi- 
ness of  the  lens.  This,  however,  is  the  exception;  the  rule  being  that  for- 
eign bodies  will  lead  to  a  complete  cloudiness,  even  where  the  cloudiness 
remained  partial  for  a  long  time.  This  condition  seems  to  be  analogous 
to  the  congenital  partial  cataracts.  Hence  one  must  not  be  astonished  if, 
after  an  extraction,  one  finds  that  the  cataract  which  we  considered  as  an 
ordinary  senile  cataract,  should  be  found  to  contain  a  foreign  body.  Work- 
ers in  metals,  who  are  so  accustomed  to  have  particles  of  metal  fly  into 
their  eyes,  overlook  the  entrance  of  such  a  foreign  body  into  the  lens,  since 
the  aqueous  is  not  necessarily  evacuated,  and  the  reaction  must  not  neces- 
sarily be  any  greater  than  when  a  particle  is  imbedded  in  the  cornea.  If 
now  the  lens  should  cloud  up  but  slightly,  and  in  fact,  very  slowly,  the  oc- 
currence of  the  injury  will  in  all  probability  be  forgotten  before  the  dis- 
turbance of  vision  is  noticed. 

One  most  frequently  observes  the  retention  of  a  foreign  body  where  it 
is  very  small  and  not  too  heavy.  In  these  cases,  most  probably,  the  scler- 
osed nucleus  holds  the  foreign  body  fast.    The  case  of  Parnard,  in  which  he 


254 

was  enabled  to  see,  and  later  extract,  a  grain  of  shot  out  of  the  lens,^  de- 

sen^es  to  be  classed  as  a  great  curiosity. 

It  occurs  much  more  frequently,  that  the  foreign  body  which  pene- 
trates, passes  through  the  lens.  Even  in  such  cases,  the  openings  in  both 
capsules  may  close  again.  This  occurs  most  frequently  when  both  point 
of  entrance  and  of  exit  are  in  the  periphery  of  the  lens,  the  healing  of 
the  anterior  capsule  being  again  aided  by  the  iris.  The  posterior  wound, 
however,  is  under  more  favorable  conditions,  since  the  vitreous  has  less 
tendency  to  dissolve  the  lens  fibres. 

Where  the  penetrating  body  is  of  considerable  size,  or  where  by  chance 
the  capsular  wound  happens  to  be  a  large  one,  the  lens  becomes  cloudy  in 
proportion  to  the  area  which  comes  in  contact  with  the  fluid  media  of  the 
eye;  and  it  depends  largely  on  the  amount  of  general  injury  which  the  eye 
has  received  whether  the  lens  will  be  partially  or  totally  resorbed,  and 
whether  the  eye  will  be  destroyed  by  iridocyclitis,  choroiditis  or  panopthal- 
mitis. 

No  case  has  been  observed  where,  following  the  entrance  of  a  foreign 
body  into  the  lens,  and  its  remaining  in  situ,  or  after  its  passage  through 
the  lens,  the  lens  either  spontaneously  cleared  up  again,  or  remained  en- 
tirely transparent  from  the  beginning.  Hence  the  cases  reported  by 
Desmarres  tils  ^  can  only  be  looked  upon  with  doubt,  as  to  their  correct 
observation. 

Opening  of  the  capsule,  in  consequence  of  a  perforating  corneal  ulcer, 
is  likewise  to  be  looked  upon  as  an  injury  of  the  lens.  The  sequelae,  as 
far  as  the  lens  is  concerned,  depend  on  how  much  of  its  substance  is  lost, 
or  is  later  on  absorbed  by  the  aqueous.  Sometimes  the  shrunken  lens  re- 
mains adherent  to  the  cornea  and  iris,  owing  to  new-formed  cicatrical  tis- 
sue; again,  it  returns,  in  a  greater  or  less  degree,  to  its  normal  position. 
Aside  from  the  fact  that  the  lens,  together  with  its  capsule,  may  entirely 
leave  the  eye,  at  times  the  only  remains  is  a  cataracta  secundaria. 

The  appearance  of  a  traumatic  cataract  is  that  of  a  soft  cortical  cata- 
ract. The  rapidity  with  which  the  lens  becomes  cloudy  depends  on  the 
extent  of  the  injury  and  the  age  of  the  individual.  Since  young  people  are 
more  exposed  to  such  injuries  than  older,  hence  in  this  we  find  a  further 
reason  why  the  traumatic  cataract  as  a  rule  is  soft.  The  chemical  constitu- 
tion of  the  foreign  body  \nll  affect  the  color  of  the  cataract,  and  whenever 
the  well-known  color  is  wanting  the  suspicion  of  a  foreign  body  in  the  lens 
ought  to  be  aroused. 


BAnnal  d'Oeulistic.  43,  23. 

6  Le  cons  Cliniques  sur  la  Cliirurgie  Oculaire,  p.  90. 


255 
It  is  a  well-known  fact,  that  traumatic  cat;u;i<t  i-  a  perfectly  passive 
change  in  the  lens  substance.  Immediately  ujjoh  injuiy  of  its  capsule,  the 
lens  substance  comes  in  direct  contact  with  the  aqueous,  and  as  a  result  the 
lens  becomes  cloudy  and  swells  up.  As  has  already  been  pointed  out,  in 
studying  capsular  cicatrices,  page  90,  if  the  opening  is  very  minute,  this  is 
soon  plugged  up  by  a  thin  fibrinous  covering,  and  in  the  course  of  a  few 
days  a  cicatrix  covers  the  wound.  But  where  the  injury  of  the  capsule  has 
been  more  severe,  the  edges  retract,  curl  up  outwardly,  and  the  aqueous 
comes  in  direct  contact  with  the  lens  substance.  Those  portions  of' the  lens 
which  have  exuded  are  gradually  resorbed  and  disappear,  while  new  flakes 
continue  to  well  forth  from  the  capsular  wound.  At  the  same  time,  due  to 
the  taking  up  of  water,  the  lens  continues  to  swell  up  and  the  cloudiness  to 
increase,  until  in  the  course  of  a  few  days  or  weeks,  the  entire  lens  may 
become  opaque. 

But  not  alone  to  the  aqueous  is  due  the  resorption  of  the  lens  fibres. 
In  the  disintegrating  masses  of  lens  substance  and  around  the  zone  of  re- 
sorption of  larger  pieces  of  lens  fibres,  one  finds  numbers  of  lymphoid  cells 
which  take  on  the  most  manifold  changes  in  form.  These  cells  contain  two 
nuclei  and  a  dark,  granular  protoplasm,  which  might  be  looked  upon  as  fat 
granules.  These  cells  and  their  relation  to  the  resorption  of  traumatic 
cataract,  are  better  understood  today,  as  the  result  of  Boe's  experimental 
investigations;  and  he  looked  upon  them  as  derived  from  lymphoid  cells. 
.Boe  also  drew  attention  to  numerous  cells  containing  myelin  drops,  which 
subsequently  assumed  such  size  as  to  restrict  the  protoplasm  of  the  cell  to 
a  narrow  zone  around  the  myelin  drop  and  pressed  the  nucleus  against  the 
cell  wall.  Kostenitisch  '^  likewise  observed  the  presence  of  lymphoid  cells 
in  the  masses  of  lens  substance,  and  so  illustrated  them.  In  a  recent  work 
by  Wagenman,^  the  presence  of  these  cells,  also  of  giant  cells,  and  their 
relation  to  the  absorption  of  traumatic  cataract  is  made  the  subject  of 
special  study.  He  states,  "repeatedly  have  I  found  that  giant  cells  stand 
in  very  close  relation  to  the  absorption  of  lens  fibres,  and  more  especially 
in  this  case,  in  traumatic  cataract."'  In  all  the  cases  which  he  studied  he 
found  giant  and  lymphoid  cells.  These  cells  not  only  contained  albuminous 
and  myelin  drops,  but  pieces  of  lens  fibres  and  quantities  of  lens  substance 
undergoing  all  degrees  of  metamorphosis.  He  states,  that  the  change  within 
this  cell  is  undoubtedly  due  to  the  digestive  power  of  the  protoplasm. 
"This  power  of  bringing  about  retrogressive  changes  in  the  lens  substance 


7  Path.    Anat.    Untersuchungen    uber    die    Zunthutchen    Verletzungen    des 
Menschlichen  Auges.    Graefe  Arch.,  Vol.  XXXVII.  4. 

8  Einiges   uber   FremdUorper  Riesen  Zellen   ira   Auge.    Graefe   .\rch..    Vol. 
XLII,  Part  2.. 


256 

or  its  derivatives  taken  up  b}'  the  cells,  is  especially  marked  in  the  giant 
cells,  in  which  one  can  find,  side  by  side,  the  most  varied  products  of  disin- 
tegration of  lens  substance,  intact,  and  myelin  globules  undergoing  gran- 
ular degeneration,  hyaline  drops,  etc. 

He  assumes  that  these  giant  cells  possess  the  power  of  exerting  a  cata- 
lytic action  on  the  hard  lens  siibstance,  dissolving  and  absorbing  it,  and  he 
ascribes  this  same  power  to  the  smaller  cells. 

One  of  his  cases  is  of  exceptional  interest,  because  it  throws  a  good  deal 
of  light  on  a  subject  which  has  long  been  in  dispute,  namely,  whether  wan- 
dering cells  could  pass  through  an  uninjured  capsule. 

Case  of  spontaneous  resorption  of  a  luxuated  cataract  in  an  eye  suffering 
from  chronic  irido  choroiditis. 

"In  the  lower  segment  of  the  globe  posterior  to  the  ciliary  body,  the  lens 
is  in  such  a  position  that  its  former  lower  edge  touches  the  wall  of  the  globe 
and  the  lens  is  directed  obliquely  backward,  with  its  former  anterior  surface 
looking  upward.  The  lower  edge  of  the  lens  appears  to  be  fixed  by  new  con- 
nective tissue,  and  in  the  region  of  the  orra  serrata  it  is  partially  calcareous, 
and  beneath  the  folded  anterior  capsule  is  an  old  capsular  cataract. 

"The  capsule  of  the  lens  discloses  numerous  interspaces,  and  in  some  places 
splits,  due  to  the  action  of  the  lymphoid  cells,  even  in  the  region  of  the  capsular 
cataract,  defects  are  found  in  the  capsule.  Within  the  capsular  sac  are  groups 
of  lymphoid  cells,  especially  between  the  capsular  cataract  and  the  body  of 
the  lens;  likewise,  between  the  posterior  capsule  and  the  lens.  Over  large 
areas  the  body  of  the  lens  is  clothed  with  a  layer  of  large  tumescent,  single  or 
multi-nuclear  cells,  containing  an  opaque  protoplasm,  and  besides  these  all 
stages  of  lymphoid  cells  occur. 

"Everywhere  the  cataract  has  the  appearance  as  though  it  had  been 
"gnawed  at."  Cells  have  worked  their  way  in  between  the  sclerosed  fibres  and 
have  separated  them.  Everywhere  the  cataract  is  being  absorbed.  Giant  cells 
are  also  found,  which  are  closely  applied  to  the  side  of  the  fibres.  It  appears 
as  though  the  processes  of  the  cells  were  forcing  their  way  in  between  the 
fibres.  These  giant  cells  contain  a  uniform  granular  protoplasm,  and  differ 
from  the  other  cases  in  that  no  pieces  of  lens  fibre  or  myelin  drops  could  be 
found." 

Here  the  capsule  of  the  lens  disclosed  numerous  perforations,  due  to 
the  Mstolytic  action  of  the  cells.  The  giant  cells  possess  this  same  histolytic 
power  of  dissolving  substances  chemically  resistant  and  difficult  of  assimila- 
tion, such  as  the  hyaline  membranes.  This  action  on  the  capsule  is  cataly- 
tic, ("fernwirkung"),  and  finds  its  analogue  in  the  action  of  the  lymphoid 
cells  in  inflammatory  processes,  and  in  the  action  of  osteoclasts  in  the  re- 
sorption of  bone." 

Leber  ^  has  experimentally  shown  that  the  lens  reacts  but  slightly  to 

9  Enstehung  der  Entzundung,  p.  254,  etc. 


257 
tlie  presence  of  fofciuii  bodies.  Where  pieces  of  sterilized  copper  wire 
were  passed  tlirough  tlie  lens  in  ;in  ;i\i;d  direction,  the  centre  of  the  len? 
remained  perfectly  clear,  only  at  the  points  of  entrance  and  exit  in  the 
cortical  substance  did  any  swelling-  and  cloudiness  lake  [ilace. 

]ii  conrse  of  time,  as  was  to  be  expected,  the  cloudiness  went  on  to  the 
formation  of  striae  in  the  anterior  eorticalis.  but   the  g-reater  part  of  tlie 
lens  remained  perfectly  clear.    After  a  time  the  lens  took  on  a  dirty  yellow 
color.    Forlanini  '"^  showed  that  at  times  splinters  of  wood  remained  as  long 
as  ten  days  in  the  lens  without  producing  more  than  a  circnmscript  cloudi- 
ness at  the  point  of  entrance.     In  considering  the  action  of  foreign  bodies 
of  iron  and  steel  in  the  crystalline  lens.  Tjcber  (cited  p.  9(1)  states,  "It  is 
a  well-known  fact,  that  splinters  of  iron  and  steel  imbedded  in  the  lens  may 
remain  permanently,  without  doing  any  damage  to  the  eye.     The  never- 
failing  cloudiness  of  the  lens,  in  and  of  itself,  is  not  to  he  looked  upon  as 
the  result  of  the  action  of  the  foreign  body.    But  even  in  these  cases,  after 
a  time  the  metal  undergoes  a  partial  dissolution,  and  later  a  kind  of  dif- 
fusion for  a  certain  distance  beyond  the  foreign  body,  and  thus  gives  the 
cataract  a  rusty  yellow  color.     Von  Graefe,  in  his  clinical  lectures,  often 
said  that  the  coloring  of  the  lens  is  so  characteristic,  that  it  is  certainly 
pathognomonic  of  the  presence  of  an  iron  splinter,  where  this  can  not  be 
directly  seen  or  demonstrated.    The  color  is  due  to  the  deposit  of  the  most 
minute  granules  of  the  hydrated  oxide  of  iron,  as  is  shown  by  the  fact,  that 
when  they  are  acted  on  by  nitric  acid  and  ferrocyanide  of  potassium,  they 
give  a  blue  color.     This  has  been  repeatedly  demonstrated  on  freshly  ex- 
tracted lenses  which  contained  splinters  of  iron.    Macroscopically,  the  lens 
has  a  peculiar  olive-brown  color,  since  the  color  is  diffused  for  a  certain 
distance  beyond  the  foreign  body,  the  iron  must  be  diffused  in  the  form 
of  the  acid  carbonate  of  iron,  and  this,  by  further  oxidation,  is  precipitated 
as  the  hvdrated  oxide  of  iron. 


SECONDARY  CATARACT.  (Intentional  injuries).  A  necessary 
condition  for  the  formation  of  a  secondary  cataract  must  always  be  a  partial 
or  total  retention  of  the  capsule  of  the  lens  within  the  eye  after  an  extrac- 
tion. Only  where  the  ideal  operation  is  done  and  the  lens  is  extracted  in 
its  capsule,  is  this  formation  avoided.  Where  the  lens  substance  which  re- 
mains after  an  extraction  and  the  capsular  epithelium  alone  are  involved, 
we  designate  the  new  formation  as  a  cataracia  secundaria  simple.v;  but 
where  neighboring  tissues — iis  iris,   corpus  ciliarc,   and   vitreous — are  in- 


10  Annal  di  Opthal.,  I.  p.  145.    1871. 


258 

volved,  or  abnormal  adhesions  are  found,  we  speak  of  a  cataracta  secundaria 

accreta,  cataracta  complicata. 

This  condition  may  develop  after  a  total  resorption  of  the  lens  sub- 
stance subsequent  to  an  injury  accidentally  or  intentionally  pro- 
duced, as  the  result  of  operative  interference  when  a  discission  is  made  or, 
as  is  more  frequently  the  case,  after  an  extraction. 

Immediately  after  incision  of  the  capsule  and  extraction  of  the  lens, 
owing  to  the  pressure  of  the  vitreous  the  curvature  of  the  posterior  capsule 
is  reversed,  its  convexity  now  facing  anteriorly.  The  triangular  flaps  in 
the  capsule  produced  by  the  cystitome  are  everted  outwardly,  so  that  all 
around  the  periphery,  the  capsule  is  intact;  whereas,  in  its  central  posi- 
tion there  is  a  defect,  the  anterior  surface  of  the  posterior  capsule  coming 
in  contact  with  the  aqueous.  After  the  anterior  chamber  is  again  restored, 
the  capsule  is  pressed  backward  again,  so  that  the  posterior  capsule  is 
almost  perfectly  straight  and  the  edges  where  the  anterior  capsule  is  everted 
come  in  contact  with  the  posterior,  and  thus,  if  we  may  so  express  it,  a  cir- 
cular pocket  is  formed  all  around  the  periphery,  and,  as  a  rule,  this  pocket 
contains  lens  substance  which  has  remained  behind  after  the  operation,  and 
the  products  of  new  cellular  formation  originating  from  the  epithelial  cells 
which  line  the  capsule.  This  formation  has  been  designated,  Sommering's 
crystalline  pearl  (or  wulst).  Owing  to  the  changed  "conditions  of  pressure, 
these  new-formed  cells  assume  a  great  variety  of  forms;  in  fact,  all  of  those 
already  described,  the  large  vesicular  cells,  Wedl's  cells,  irregularly  devel- 
oped cells,  with  protuberances  to  the  one  side,  etc.  This  cellular  prolifera- 
tion does  not  only  take  place  between  the  leaves  of  the  capsule,  but  at  the 
edge  of  the  crystalline  pearl  one  finds  a  hyperplasia  of  the  capsular  epithe- 
lium going  over  onto  the  anterior  surface  of  the  posterior  capsule.  Here 
they  no  longer  have  the  shape  of  the  normal  epithelial  cells,  but  are  more 
like  flat  pavement  epithelial  cells,  which  likewise  undergo-  a  hyperplasia. 
These  cells,  after  a  certain  length  of  time,  secrete  a  vitreous  or  hyaline-like 
substance,  which  forms  a  covering  for  these  cells  and  the  posterior  capsule. 
It  is  the  product  of  this  hyperplasia  of  epithelial  cells  which  gradually 
causes  the  interference  with  vision  subsequent  to  a  cataract  operation.  Just 
exactly  what  it  is  that  leads  to  this  regeneration  it  is  difficult  to  state,  but 
undoubtedly  the  cells  possess  a  tendency  to  regeneration  which  is  incited 
by  the  operation  and  the  changed  relations  of  tension  and  pressure. 

In  all  these  cases  one  finds  the  pupillary  area  occupied  by  a  very  deli- 
cate greyish,  almost  transparent,  film,  discernible  on  oblique  illumination, 
and  which  permits  of  a  red  reflex  from  the  fundus.  All  gradations  are  met 
with,  from  this  delicate,  scarcely  visible,  greyish  film,  up  to  the  dense  white 
membranous  cataract. 


259 
'"It  not  infrequently  occurs  that  tlie  resnlt  of  a  successful  opei'ation  is 
reduced  by  the  retention  of  cataractous  masses  within  the  capsular  sac.  Tliis 
is  especially  apt  to  occur  when  an  unripe  cataract  is  operated,  but  does 
occur,  oven  in  the  ripe,  if  the  opening  in  the  anterior  capsule  is  suffi- 
ciently large,  the  masses  wliicli  remain  swell  up  and  are  resorbed.  In  this 
case  the  pupil  finally  becomes  pure  black.  But  where  the  leaves  of  the 
capsule  are  rapidly  closed  and  the  retained  masses  are  cut  off  from  the 
aqueous,  these  are  not  resorbed,  but  remain  behind,  forming  a  white  mem- 
branous cloudiness,  {catarada  secundaria).  If  a  portion  of  the  pupil  re- 
mains free,  sight  may  be  good.  But  if  the  entire  pupil  is  involved,  vision 
is  reduced,  depending  on  the  density  of  the  cloudiness.  At  times  the  sec- 
ondary cataract  forms  later  on,  as  a  result  of  hyperplasia  of  the  epithelium 
of  the  anterior  capsule."  '■'■ 

11  Fuchs  Lehrbuch  der  Augeuheilkunde,  1891,  p.  763. 


PART  IV. 

THE  THEEAPY  OF  THE  DISEASES  OF  THE  LENS  SYSTEM. 

At  the  present  day  the  therapy  of  cloudiness  of  the  lens  is  confined  en- 
tirely to  operative  procedure.  True,  we  might  consider  proplylactic  meas- 
ures— but  even  these  must  remain  restricted  to  certain  special  varieties, 
such  as  traumatic  cataracts. 

CHAPTER  1. 

MEDICINAL  TEEATMENT. 

"From  the  earliest  times,  have  not  only  the  most  manifold  suggestions 
been  offered  to  bring  about,  by  medicinal  treatment,  the  disappearance  of 
a  beginning  cloudiness  of  the  lens  in  cases  of  partial,  and  even  total,  cata- 
racts, but  frequently  those  have  come  forward  who  claim  good  results  from 
such  efforts.  But  I  will  spare  myself  and  the  reader  the  trouble  of  enum- 
erating all  those  things,  which  have  been  tried  and  reported  as  worthy  of 
a  trial,  for  this  would  necessitate  my  beginning  with  the  'honey  and  saf- 
fron, cooked  in  the  bile  of  hyenas,'  of  Plinius  (XXVIIL,  8),  and  mention- 
ing all  the  remedies  down  to  dilute  phosphoric  acid,  which  but  a  few 
months  ago  (1876)  was  praised  in  many  political,  and  even  scientific,  papers, 
both  in  France  and  Germany,  as  a  universal  remedy  for  grey  cataract;  and 
could  thus  fill  pages  with  the  recitation  of  such  unproven  things."  More 
recently,  one  reads  of  the  beneficial  effects  of  electricity,  the  mysterious 
agent  to  which  so  many  turn  when  everything  else  fails.  If  it  is  possible 
anywhere,  it  is  certainly  demonstrated  here,  that  unless  we  possess  a  perfect 
knowledge  of  the  causation,  no  successful  therapy  can  ever  be  evolved. 
Hence,  all  therapeutic  attem])ts  rest  on  the  purest  emjiivicism. 

"If  any  one  is  interested  in  tliis  subject,  and  lias  a  desire  to  look  up  all 
these  suggestions  in  detail,  he  will  find  all  the  old  literature  on  the  subject  col- 
lected and  made  use  of  in  Rosa's  'Handbueh  der  Heilkundo,  1830.  II.  p.  710,' 
and  in  Himly's  'Die  Krankholten  uud  Missbildungen.  etc.,  II,  p.  247;"  The 
latest  literature  can  V)e  found  in  the  hiiiliouiai'liy  ;iunt'.\e(l."' 

Although  up  to  the  present  time  we  have  not  attained  any  results,  we 
must  not  entirely  set  aside  the  possibility  that  the  time  may  come,  when 
it  will  become  possible  to  arrest  further  development  of  a  beginning  cata- 
ract, or  even  clear  up  an  opacity  which  has  already  developed.  The  experi- 
ments of  Kunde  {82S)  and  Kuhnhorn  (843)  liave  denumstrated  that  the 


26t 

lenses  of  animals  which  have  Ix'cii  nia(h'  clondy  hy  drawino-  out  tlicir  water 
can  again  be  cleared  up,  by  simply  laying  them  in  water.  At  this  point,  I 
would  once  more  draw  attention  to  the  facts  recorded  in  the  earlier  parts 
of  this  work  regarding  the  chemical  constitution  of  the  senile  non-cataract- 
ous  lens  and  the  cataractous  lens  of  the  same  age  of  life,  and  that  the 
nucleus  of  a  senile  cataract  has  a  different  constitution  from  the  nucleus 
of  a  senile  non-cataractous  lens;  also,  to  the  wonderful  and  surprising  con- 
clusions to  which  these  facts  have  led  Becker.  (See  section  on  "Senile 
Cataract,  on  page  <J;34.) 

As  is  evident  from  a  careful  study  of  all  that  so  far  has  been  said, 
every  variety  of  cataract  which  is  not  a  congenital  malformation  or  disease, 
or  which  is  of  traumatic  origin,  is  either  secondary  to  some  disease,  either 
local  in  the  eye,  or  to  some  general  disease  of  the  entire  organism.  With 
a  more  complete  knowledge  of  the  causation  of  these  latter  forms  of  cata- 
ract, we  may  hope,  by  applying  the  proper  treatment  at  the  proper  time,  to 
prevent  their  occurrence,  but  I  do  not  believe  that  we  will  ever  succeed  in 
causing  a  retrogression  after  the  processes  of  cataract  formation  have  once 
been  started. 

Eduard  v.  Yager,  out  of  a  large  number  of  cases  in  which  he  made  a  diag- 
nosis of  clearing  up  of  a  cloudy  lens,  reports  two  in  detail  (p.  917).  Both  are 
cases  of  cortical  cloudiness  (one  anterior  and  one  posterior).  The  one  occurred 
in  a  man  25  years  of  age,  whom  he  had  had  under  observation  for  four  years; 
the  other  in  a  woman  42  years  of  age,  who  was  under  observation  for  twelve 
years;  however,  never,  even  where  the  senile  change  was  of  the  most  minute 
kind,  did  lie  see  the  cloudiness  totally  disappear. 

If  we  are  to  designate  every  true  cloudiness  which  occurs  in  tlie  periphery 
of  every  senile  lens  as  a  cataract  incipiens,  I  can  uot  agree  to  the  truth  of  this 
general  proposition.  Becker  reports  the  following  case:  "For  the  past  five 
years  I  have  known  a  gentleman  and  a  lady,  in  whose  eyes  as  long  ago  as  re- 
sjiectively  twelve  and  fifteen  years,  the  opthalmoscopic  examinaticm  was  made 
by  men  of  reputation  and  ability;  colleagues  whose  veracity  is  not  doubted, 
and  I  hold  their  affidavits  that  at  that  time  cataract  was  diagnosticated,  and 
that  the  disease  has  not  progressed  since  that  time.  But  I  also  possess  the  most 
convincing  proof  in  an  observation,  in  which  I  myself  made  the  diagnosis  of 
catai'act  on  both  eyes  of  a  lady,  the  wife  of  one  of  my  colleagues,  which  have 
since  totally  disappeared  again." 

Stellway  (p.  603)  likewise  seems  to  have  frequently  observed  similar  cases. 
He,  however,  does  not  attempt  to  explain  them  as  true  opacities,  but  considers 
them  as  gcronto.ron  leiitis  (Amnion).  Relative  to  traumatic  cataracts  we  possess 
the  beautiful  observations  of  V.  Rydel  (1107),  which  have  since  been  corrobor- 
ated by  the  observations  of  others.  An  early  closure  of  the  point  of  entrance 
is  favorable  to  such  a  clearing  up.  The  isolated  observations  which  V.  Dietrich 
made,  while  making  his  well  known  experiments,  also  belong  in  the  category. 


262 

Hol^eher  i  refWMTS  two  oases  where  chadren  at  binh  had  cataract,  and  after 
the  dose  of  the  second  year  these  lenses  commenced  to  dear  np.  beginning  at 
the  periphery.  In  the  beginning  in  simple  sectors,  nnril  finally  they  were  en- 
tirely free  of  opacities.  In  the  fifth  year  they  had  entirely  cleared  np  inside  of 
the  capsnle. 

Under  the  title  of  "'Spontaneous  Cataract  Cure.''  we  find  reported  in  litera- 
ture a  series  of  cases  of  spontaneous  resorption  and  luxation.  These  are  nearly 
all  cases  in  which  vision  was  lost,  owing  to  the  c-ataract.  and  had  again  been 
spontaneously  restored:  not  however,  due  to  a  retrogression  of  the  processes 
of  cataract  formation-  Here  in  a  certain  number  of  cases,  ivithout  operative 
interference  or  trauma,  a  result  was  obtained,  such  as  is  purposely  sought  by 
operative  interference.    Some  of  the  cases  are  worthy  of  being  recorded. 

Tht^  spontaneous  resorption  of  a  c^taractous  lens  without  an  injury  of  the 
capsule.  A  man.  4C»  years  of  age,  who  subjected  himself  to  a  "starvation  cure" 
for  rheumatism  and  gout,  became  affec-ted  with  soft  cataract  on  both  eyes, 
■without  sufiFering  any  pain  or  inflammatory  symptoms.  Without  the  interven- 
tion of  any  operative  proceedure  both  cataracts  were  resorbed  in  the  course  of 
a  few  years,  more  qtiickly  on  the  right  than  on  the  left  eye.  so  that  he  was 
enabled  to  read  without  the  use  of  glasses  by  holding  large  print  closely.  ( War- 
natZL  435.)  (This  was  tmdoubtedly  a  cataracta  Morgagni.  with  total  resorption 
even  of  the  nucleus.  • 

Cataract  develc^>ed  in  both  eyes  of  a  woman  45  years  of  age.  Setons  were 
put  on  both  arms  and  laxatives  were  administered  at  the  same  time,  and  at 
intervals  ctips  were  also  applied.  After  a  duration  of  five  years  the  yellowish 
white  cataract  became  more  cloudy  in  both  eyes:  did  not.  however,  become 
resorbed  from  the  periphery  to  the  center,  but  had  a  fractured  and  divided  ap- 
pearance, a  stariike  configuration,  almost  like  the  figures  seen  after  a  kerato- 
nyii*.  Resorption  progres.aed  so  rapidly  that  at  the  end  of  six  months  both 
pupiLs  were  pure  Wack.  and  every  cataractous  di-scoloration  of  the  lens  had 
disappeared-  This  patient  used  spectacles.  iWamatz.»  ^Likewise  a  cataracta 
MorgagnianL) 

To  these  case*,  taken  from  the  pre-opthalmoscopic  literature.  Becker  adds 
the  clinical  report  of  a  case  kindly  given  to  him  by  bis  friend.  Dr.  Brettauer,  of 
Triest  which  may  serve  to  put  these  observations  of  Wamatz  in  their  proper 
light,  and  serve  to  plac-e  the  possibility  of  a  lens  being  spontaneously  resorbed 
within  its  capsnle  in  its  proper  light. 

March  20.  1862.  Mr.  Z.,  aged  35  years.  <^ame  to  me  for  treatment.  Ou  the 
right  eye  he  bad  a  ripe  cataract,  a  milky  white  corticalis,  presenting  no  special 
features.  Beneath  the  capsule  were  a  few  white  chalky  nodules,  about  one-half 
the  size  of  the  bead  of  a  pin:  and  the  nacletis  could  be  differentiated.  On  the 
2fjih  of  >Iarcb  the  right  eye  was  operated  bj  a  flap  extraction  downward,  with- 

1  Walter  and  Ammon  Journal.  XXXII.  p.  219. 


out  an  iridectomie.  Imm^luitelT  after  introduction  of  the  cy^totome  the  vitre- 
ous prolapksed.  At  the  same  moment  the  cataract  disappeared  out  of  the  pupil- 
h^.ry  area.  Whether  the  entire  t-ataraft  was  llui^L  or  whether  the  Tirre^.us 
caused  the  nucleus  to  be  dragged  out  of  the  eye.  could  not  be  determined,  as 
the  accident  reiiuired  mv  undivided  attention.  We  hunted  for  the  cataract 
on  the  bed  and  on  the  floor,  but  it  could  not  be  found.  During  the  healing  pro- 
cess blood  filled  the  pupillary  area  for  a  long  time,  and  the  iris  cicatrised  in  the 
wound.  August  4th.  with  a  —  «-  the  patient  could  read  Yager  No.  S.  and  with 
a  —  '6  the  numbers  of  the  houses  across  the  street.  The  restilt  was  perma- 
nent, since  with  this  one  eye  he  was  enaMed  to  follow  his  occupation,  that  of 
a  hat  maker,  and  at  the  end  of  twelve  years  "March.  1ST4»,  with  ~-  i^  V  =  f,. 
When  he  came  again,  in  ISTI.  to  have  his  glasses  changed.  Dr.  Brettauer.  who 
had  not  seen  the  patient  since  the  operation,  noticed  a  trembling  aini  discolora- 
tion of  the  left  iris,  which  was,  however,  round  aiHl  reacted  to  light.  In  the 
center  of  the  pupil  was  an  irregttlar  star-shaped  meml»rane.  This  disc4iTc?ed. 
on  dilating  the  pupil,  going  out  from  the  central-shaped  membrane  correspond- 
ing with  the  sectors  of  the  lens;  a  grtatinous  mass,  hanging  from  which  are 
an  innumerable  number  of  cholesterine  crystals.  resemWing  the  golden  tinsel 
on  a  Christmas  tree.  Between  these  various  sectors  of  gelatiiK>«s  stibstances, 
we  can  get  a  red  reflex  from  the  fundus  by  means  of  the  opthAlmoscope.  ♦Beck- 
er saw  this  case  in  1S72.>  March  2.  1S74.  this  trembling  of  the  iris  had  ii»- 
creased:  the  gelatinous  mass  as  a  whole  had  grown  less,  likewise  the  number 
of  crystals.  Downward  and  outwaril  a  sector  of  gelatinous  substaiKV  seemed 
to  lie  anterior  to  the  plane  of  the  central  membrane.  Immediately  posterior 
to  the  leas  one  could  see  a  number  of  easily  movable  and  quite  large  vitreous 
membranes,  all  in  the  anterior  portion  of  the  vitreous.  The  [«apilla  was  slightly 
hyperaemic.  and  on  the  outer  side  a  small  conus  about  one-sixth  the  diameter 
of  the  papilla.  With  +  **,  vision  equaled  nearly  |J.  The  slightest  change 
in  the  position  of  the  glass  impaired  vision:  hence,  there  is  no  sign  of  accv^mmo- 
dation.  How  long  vision  has  been  improving  on  this  eye  Z.  is  m-»t  aWe  to  state. 
During  the  past  two  years  this  absorption  and  diminution  of  the  crystals  has 
materially  decreased.  Z.  denies  ever  having  receive*!  a  trauma,  and  it  is  not 
possible  to  demonstrate,  either  on  the  cornea  or  iris  nor  on  the  capsule,  a  cica- 
trix, a  tear  or  anything  resembling  it.  Since  the  patient  reqtiired  on  this  eye 
«  glass  of  the  same  strength  as  he  did  on  the  operated  eye.  there  can  l>e  no 
doubt  but  that  this  is  a  case  of  Sfmmtnmrtiti*  .>«..  rr,  .,  ,  -  ,i  ,■,7^^o,.  r  v-t,..  t\^ 
caf^ttlf  *«*  not  hrem  rmfttmrri.   «Bretthauer.^ 

Gilson  ip.  722"*  has  reportcil  a  case  wherx*  a  ^^nli;^•n.;u  v-s:.-iracu-^  lavua  ".-is 
resorlH-»d.  as  the  result  of  a  blow  on  the  eye.  which  ruptured  the  capsule  without 
catising  any  other  injury  to  the  coats  of  the  eye. 

Finally,  all  these  oases  belong  to  this  class,  in  which,  following  a  sjx^n- 
taner>us  sinking  of  the  cataracious  lens,  vision  is  restored.  Literature  is  full  of 
the  reiH>rts  of  such  cases.  The  oUlt^t  reiH>rts  are  by  St.  Yves,  and  Janin  re- 
ports two  oases,  'Ono  of  these  had  a  cataract  fn^m  early  youth,     SicN^K!  and 


264 

Himly  (Opthal.  Bibl..  I.  187.  1801),  in  the  reports  of  their  cases,  seem  to  have 
come  to  similar  conclusions,  in  that  pre-supposing  that  a  subluxation  had  oc- 
curred, they  gave  the  patient  suffering  from  a  "trembling  cataract"  the  advice 
to  take  jumping  exercises,  in  order  to  bring  about  a  total  luxation.  Later  on 
it  became  fashionable  to  apply  electricity  or  to  give  large  doses  of  strychnia, 
so  as  to  bring  on  a  separation  of  the  lens  from  its  connection  as  a  result  of 
muscular  contraction. 

Sperino  attempted  to  clear  up  a  beginning  or  even  fully  developed  cataract 
by  operative  means,  though  not  by  a  true  cataract  operation.  After  Hoquet, 
in  1729,and  Les  Col.  de  A'^lllars.  in  1740.  had  suggested  that  the  attempt  be  made 
by  means  of  repeated  punctures  of  the  anterior  chamber  to  influence  the  de- 
velopment of  cataract  (the  experiments  of  Dietrich  also  being  here),  Sperino 
took  up  his  experiments  in  a  more  extensive  manner,  in  that  he  did  not  restrict 
his  experiments  to  cataract  alone.  His  results  were  excellent.  A  woman  who 
could  no  longer  find  her  way  about  was  so  much  improved  by  this  method  that 
she  could  read  Yager  No.  3  without  spectacles,  and  vision  was  permanently 
improved.  In  forty  other  cataract  cases  vision  was  more  or  less  improved.  It 
is  definitely  recorded  that  the  clearing  up  was  determined  by  opthalmoscopic 
examination.  These  experiments  were  repeated,  especially  by  Sperino's  coun- 
trymen. Borelli.2  in  twenty-one  cases,  had  little  or  no  result.  Torresini  (ilid) 
even  noticed  a  rapid  increase  in  the  cataractous  cloudiness.  Rivaud  Laudran 
reported  a  case  without  any  results  at  the  Congress  held  in  Paris  in  1863.3 
Since  that  time  nothing  further  has  been  heard  concerning  Sperino's  sugges- 
tions. I  do  not  know  whether  this  subject  has  received  any  further  attention. 
Good  results  were  certainly  not  attained,  otherwise  we  would  have  heard  of 
them.  The  great  attention  which  the  experiments  of  Sperino  attracted  is  ex- 
plained by  the  fact  that  the  possibility  of  the  nutrition  of  the  lens  being  af- 
fected by  the  repeated  punctures  of  the  anterior  chamber,  could  not  a  priori 
be  denied.  It  can  not  be  doubted  but  that  by  the  repeated  evacuation  of  the 
aqueous,  the  chemical  formation  of  the  same  is  altered.  We  know  that  by 
means  of  puncture  of  the  anterior  chamber  in  cases  of  traumatic  cataract,  and 
after  discission,  we  can  hasten  the  absorption  of  the  swollen  up  lens  substance. 
Aside  from  this,  every  time  the  anterior  chamber  is  punctured,  the  lens  changes 
its  position,  which  does  not  take  place  without  at  the  same  time  the  lens  chang- 
ing its  shape,  and  consequently  the  lamellae  are  pushed  past  each  other.  If  it 
is  correct  that  there  are  always,  or  at  least  often,  a  splitting  up  of  the  lens 
during  cataract  formation,  hence  such  an  abnormal  change  in  the  form  of  the 
lens,  as  occurs  when  the  aqueous  is  evacuated,  can  not  but  influence  the  for- 
mation of  a  cataract.  One  should  at  least  incline  more  to  the  opinion,  as  Tor- 
resini observed,  that  the  cataract  formation  is  hastened  by  the  repeated  punc- 
tures. This  would  be  in  accord  with  Snellen's  verbal  statement  to  me  (Becker), 
that  the  making  of  a  preliminary  iridectomie  will  ripen  an  unripe  cataract. 

2  Gionale  d  Ottalmologia  Italiano,  18G2.  " 

3  Comptes  Rendus,  155.     See  the  discussions  in  which  Raymond.  Desmares, 
Testelin,  Borreli,  Dor,  Ricardo-Secondi  Quaglino  took  part. 


265 
CHAPTER  II. 

THE  OPERATIONS  FOR  CATARACT. 

The  true  operations  start  out  with  an  essentially  different  purpose. 
By  their  means  the  cloudiness  of  the  lens  is  not  expected  to  be  cured,  but 
rather  the  detriment<Tl  influence  which  such  a  cloudy  lens  exerts  on  vision 
is  to  be  removed.  Only  exceptionally  do  we  remove  a  cataractous  lens  in 
order  that  we  may  abate  the  disfigurement. 

The  object  of  all  operative  interference  in  primary  cataract  is  to  make 
it  possible  for  a  large  amount  of  regularly  refracted  light  to  reach  the 
retina.  This  can  be  attained  by  various  methods.  We  can  leave  the  cata- 
ractous lens  in  the  eye,  but  remove  it  from  the  pupillary  area,  by  pushing  it 
to  one  side,  or  downward  into  the  vitreous — depressio,  redinaHo,  lentis. 
We  can  remove  the  lens,  by  making  a  wound  of  sufficient  size  in  the  coats 
of  the  eye,  cornea  and  sclera,  and  thus  remove  it  at  once  from  the  eye — 
extractio,  suctio,  lentis.  By  opening  the  capsule  we  can  bring  the  lens  in 
direct  contact  with  aqueous  and  vitreous,  and  thus  bring  about  a  resorp- 
tion within  the  eye — decissio  per  heratonyxim,  et  per  scleronyxim.  Finally, 
we  may  permit  the  partially  luxated  or  partially  cloudy  lens  to  remain  Avith- 
out  interfering  with  it,  and  by  means  of  an  artificial  pupil,  bring  the  light 
unimpeded  to  the  retina — iridectomie  in  cases  of  cataract. 

A. 
DISLOCATIO     CATARACTAE,     DEPRESSIOX,     RECLIXATIO     C. 
PER    SCLEROTICOXYXIM    AUT    PER     KERATOXYXIM 
ABAISSEMENT    DE    LA    CATARACTE.     COUCH- 
ING—SUBLATIO   C,   RELEYEMENT   DE 
LA  CATARACTE. 

DEPRESSIOX. 

Definition — Every  operation  which  has  for  its  object  tlie  removal  of 
the  lens  from  the  pupillary  area,  and  the  sinking  of  it  into  the  vitreous,  by 
means  of  an  instrument  (a  needle)  , which  is  pushed  through  the  sclerotic 
or  cornea,  is  designated  by  the  words,  "^depressio  catarada,  redinatio;" 
"turning  over  of  the  cataract;  deplacement.  By  means  of  the  needle,  press- 
ure is  either  brought  to  bear  on  the  lens  from  above,  and  so  depressed  ex- 
actly downward,  {depressio  catarada — method  of  Celsius),  or  the  needle  is 
applied  to  the  anterior  surfac  of  the  lens,  and  by  this  means  the  lens  is 
turned  over  backward,  so  that  its  upper  edge  becomes  its  posterior,  and  its 
anterior  surface  its  upper,  (reclination  according  to  Willburg,  1785 — turn- 
ing over  of  the  cataract);  or  the  needle  is  turned  backward,  outward  and 
below,  at  the  moment  tlie  lens  is  being  turned  over,  so  as  to  cause  the  ante- 


266 

rior  surface  of  the  lens  to  face  the  gahella  frontls.     (Reclination  according 

to  Scarpa,  1801). 

There  are  cases  in  which  a  spontaneous  process  occurs  in  cataractous 
eye,  which  may  be  looked  upon  as  the  prototype  of  depression,  and  which 
really  lead  to  the  artificial  application  of  this  procedure.  These  are  the 
cases  of  spontaneous  sinking  of  cataractous  lenses  which  have  already  been 
considered. 

From  the  most  ancient  times  the  point  for  the  puncture  has  always 
been  in  the  sclerotic,  midway  between  the  outer  edge  of  the  cornea  and  the 
outer  canthus.  This  seemed  to  be  such  a  self-evident  procedure,  that  this 
method  of  puncture  was  never  given  a  name  (sderonyxis)  until  Buchhorn 
(1805)  began  recommending  that  the  puncture  for  the  depression  be  made 
through  the  cornea  (keratonyxis  from  zi/>«c  and  i^'jztoj  punctio  corneae). 
How  the  method  of  discission  developed  from  this  suggestion,  I  will  explain 
more  fully  when  we  come  to  the  subject  of  leratonyxis  cum  depressione 
cataraciae. 

THE  DEPRESSIO  CATARACTAE  is  the  only  method  of  which  a 
complete  and  lucid  description  has  been  handed  down  to  us  from  ancient 
times.  This  is  found  in  Celsius  (Lib.  VII.,  c.  VIII.,  14).  Owing  to  the 
extreme  importance  which  this  bears  to  the  history  of  opthalmology,  I  will 
quote  it  here  in  full: 

"Igitur  vel  ex  ictu  ooncresit  humor  sub  djuabis  tunicis  (/ft/Mirof/fW/C  et  h«/jwfMw), 
qua  locum  vacuum  esese  proposul;  isque  paulatim  indurescens  interior!  po- 
tentiae  se  oppouit.  Vitiique  ejus  plures  sunt  species;  quaedam  sanabiles,  quae- 
dam  quae  curationem  non  admittunt.  Nam  si  exigua  effusio  est.  si  immobilis, 
colorem  vero  habet  marinae  aquae,  vel  ferri  nitentis,  et  a  latere  sensum  aliquem 
fulgoris  relinquit,  spes  superest.  Si  magna  est.  si  nigra  pars  oculi.  amissa  nat- 
urali  figura,  in  aliam  vertitur,  si  suffusioni  color  caeruleus  est,  aut  auro  similis, 
si  labat,  et  hac  atque  iliac  moyetur,  vix  unquam  succurritur.  F:ere  vero  pejor 
est,  quo  ex  graviore  morbo  majoribusve  capitis  doloribus.  vel  ictu  vehementiore 
orta  est.  Neque  idouea  curationi  senilis  aetas  est,  quae  sine  novo  vitio.  tamen 
aeiem  hebetem  habet:  ac  ne  puorilis  quidem;  sed  inter  has  media.  Ooulus 
quoque  curationi  neque  exiguus,  nt-que  coucavus.  satis  opportunus  est.  At 
que  ipsius  suffusionis  quaedam  maturitas  est.  Expectandum  igitur  est.  donee 
jam  non  tluero.  sed  duritie  quadam  eoncrevisse  videatur.  Ante  curationem 
autem  modico  dbo  uti,  bibere  aquam  triduo  debet:  jtridio  ab  omnibus  abstinere. 
Post  haec  in  adv«'rso  sedili  collocandus  est  loco  liicido.  luiiiinc  :idv(M-so  sic.  ut 
contra  medicus  paulo  altius  sedeat:  a  posteriorc  aiitfiii  i>artc  c-ipnt  ejus  min- 
ister contineat.  ut  immobile  it  praestet;  nam  levi  motu  eiipi  ades  in  perpetuum 
potest.  Quin  etiam  ipse  oculus  immobilior  faciendus  est,  super  alterum  lana 
imposita  et  deligata.  Curari  vero  sinister  oculus  dextra  manu.  dexter  sinister 
debet.     Turn  acus  adinovenda  est  acuta  ut  foret,  sed  non  ninium  tenuis;  eaque 


267 
deuiittencla  recta  est  per  suiiinwis  diias  tuniciis  iiifdiu  loco  inter  oeiili  nigrum 
et  augulum  tempori  propioreui.  e  regioue  inetliae  siift'usionis  sic,  ne  qua  vena 
laedatur.  Neque  taineii  timide  demitteuda  est.  »iuia  inani  loco  excipitur.  Ad 
qiiem  qiium  ventnni  est,  ne  mediocriter  quideni  peritus  falli  potest:  quia  pre- 
meuti  nihil  reuititur.  Ubi  eo  veutum  est,  iucliuanda  acus  ad  ipsani  suffusionem 
est,  leniterque  ibi  verti,  et  paulatiin  earn  deducere  infra  regionem  pupillae  debet; 
ubi  delude  earn  trausiit,  veheuientius  iuiprimi,  ut  inferiori  parti  insidat.  Si 
haesit.  curatio  expleta  est:  si  subinde  redit.  eadeni  acu  concideuda  et  in  plures 
partes  dissipanda  est:  quae  siugulae  ea  facillus  conduntur,  et  minus  late  offici- 
wnt.  Postea  educenda  recta  acus  est,  inipouenduni(iuc  i.iii.i  niolli  exceptum  ovi 
album,  et  supra  quod  iuflammatlout'in  coerceat,  atqui-  ila  di'viucienduni.  Post 
haec  opus  est  quiete,  abstinentia,  leniura  medlcamentorum  inunctionibus,  cibo, 
qui  poster©  die  satis  mature  datur,  primum  liquido,  ne  maxillae  laborent;  deinde, 
inflammatione  tinita,  tali,  qualis  in  vulneribus  propositus  est.  Quibus  ut  aqua 
quoque  diutius  bibatur,  necessario  accedit." 

From  the  above  one  sees  that  even  Celsius  (liftereiiiiated  between  the  trau- 
matic cataract  and  the  one  due  to  internal  causes,  and  that  he  considered  all 
cataracts  not  the  result  of  trauma  as  due  to  some  disease.  He  was  even  then 
of  the  opinion  to  which  we  are  all  now  returning:  namely,  that  all  cataracts 
are  secondary  in  their  nature.  He  also  recognized  the  importance  which  the 
color  of  the  cataract  bears  to  the  prognosis.  In  that  he  separated  the  curable 
from  the  incurable.  He  acknowledged  that  there  is  hope  of  a  cure  when  there 
is  still  perception  of  light.  We  meet  with  the  expression  "ripeness  of  the  cat- 
aract," and  also  learn  that  a  preparatory  treatment  was  practiced,  and  that 
at  the  time  of  the  operation,  the  patient  was  placed  in  a  position  similar  to  that 
customary  up  to  a  few  years  ago.  (The  patient  in  a  low  chair,  the  physician 
somew^hat  higher.  Desmarres,  1252,  p.  !"►.)  An  assistant  held  the  head;  the 
other  eye  was  covered  Avith  a  bandage,  in  order  that  the  eye  to  be  operated  on 
might  remain  quiet.  The  doctor  should  be  ambidextrous.  After  the  operation 
the  patient  received  only  fluid  nourishment,  "net  maxillae  laborent."  If  we 
look  at  the  very  exact  description  of  the  operation,  one  really  can  not  tell  at 
what  one  shall  be  most  astonished;  that  Celsius  shoiild  have  had  such  a  com- 
plete understanding  of  the  operation  of  depression,  which  up  to  a  few  years 
ago  was  so  frequently  made,  or  that  this  method  should  not  have  materially 
improved  until  after  the  discovery  of  the  extraction,  which  robbed  it  of  its 
supremacy  and  caused  it  to  be  almost  entirely  abandoned. 

The  only  change  from  the  methods  of  Celsius  in  ancient  times,  is  con- 
fined to  the  instruments.  Instead  of  the  round-pointed  needle  of  Celsius, 
we  gradually  came  to  use  the  myrtle-leaf -shaped  needle  of  Brisseau.  This 
change  was  first  suggested  by  Giinz  (1750)  and  was  first  carried  out  by 
Willburg  (1785),  and  was  the  cause  of  the  introduction  of  llic  naiiio  irclina- 
tion.  The  lateral  displacement  of  the  lens  (drprc^sio  latcnilis.  1801)  was 
first  suggested  by  Bell  and  was  (iist  introduced  into  practice  by  Scarpa,  and 


this  was  greatly  facilitated  by  the  use  of  a  eatai-act  needle,  which  was  mod- 
erately cun-ed  on  the  flat  at  its  point,  and  even  today  this  needle  bears 
Scarpa's  name.  The  suggestion  of  Pauli,  1858,  (450)  is  to  be  looked  upon 
as  an  error — suUalio  catarade,  reUvement  de  la  catarade. 

The  words  of  Celsius  may  be  interpreted  to  mean  that  the  needle 
.should  be  so  introduced  from  the  beginning,  that  the  point,  by  being  simply 
pushed  forward,  will  reach  the  upper  edge  of  lens.  Later  on,  we  diverged 
from  this,  in  that  the  needle  was  introduced  perpendicularly  through  the 
coats  of  the  eye,  and  the  attempt  was  made,  by  Just  touching  the  upper  edge 
of  the  lens,  to  reach  the  posterior  chamber.  If  by  this  means  the  certainty 
of  depressing  the  lens  was  increased,  the  amount  of  damage  to  the  interior 
of  the  eye  must  likewise  have  increased,  owing  to  the  movements  of  the 
needle.  The  methods  of  Willburg  and  Scarpa  must  likewise  have  led  to 
more  extensive  destruction  of  the  vitreous,  than  where  the  typical  opera- 
tion of  Celsius  was  practiced.  If,  owing  to  the  lens  rising  up  again,  they 
were  compelled  to  break  the  lens  into  a  number  of  pieces  ("eadem  acu  con- 
cidende  et  in  plures  partes  dissipanda,  Celsius")  the  destruction  of  the 
vitreous  could  surely  not  have  been  less  extensive,  even  where  this  method 
was  practiced. 

Since  the  time  of  Buchhorn's  suggestion,  depressio  per  corneam  has 
also  been  practiced,  (depressio  per  corneam,  per  keratonyxim).  It  appears 
however,  that  this  method  is  of  earlier  date.  For  it  is  said,  that  among 
nations "  which  are  somewhat  removed  from  our  civilization  (as,  for  in- 
stance, in  Koumania)  skilled  women  who  are  not  physicians,  even  today, 
practice  this  method  (depressio  per  corneam)  by  means  of  thorns  of  the 
Lycium  Europaeum  which  have  been  hardened  by  fire.  Who  will  fail  call- 
ing to  mind  the  fable  of  the  goats? 

Tradition  tells  us  that  the  ancients  ascribed  the  discovery  of  reclination  to 
observations  which  were  made  on  goats.  It  is  really  worth  while  stopping  and 
critically  examining  this  story. 

Pliuiusi  tells:  "Oculos  subfusos  cnpra  iinici  puncto  sanguine  exonerat  caper 
rubi."  It  is  not  difficult  to  form  an  UW:i  how  the  sentence  came  to  be  written. 
No  doubt  goats  were  observed  which  liad  wounded  themselves  with  a  thorn, 
and  they  must  have  had  a  subconjunctival  hemorrhage,  and  at  the  same  time  a 
i<uffi(sio;  therefore,  a  cloudiness  in  the  pui)il.  whioh  might  eitlier  have  been  a 
true  cataract,  or  an  occlusion  of  the  pupil,  or  possibly  a  hypopyon.  The  trau- 
matic cataract  must  consequently  have  been  the  result  of  the  injury  by  means 
of  the  thorn,  and  not  an  injury  of  the  eye  by  means  of  the  thorn,  purposely 


1  Ed.  Sittlg,  VIII,  201,  p.  131. 


269 
produced  in  order  to  remove  a  eataract.  riinius  even  goes  so  far  as  to  imagine 
that  the  animal  liad  purposely  caused  a  local  bloodletting,  in  order  to  relieve 
itself  of  the  eye  disease.  Plinlus.  however,  says  nothing  regarding  the  cure 
of  cataract. 

In  tlie  "lutroductio  sen  niedicus."  wliicli  is  .isciihed  io  (Jalcn.  we  find,  in 
Chapter  1,  tlie  following  interesting  statements  (I'M.  Kuiin  tom  XI\'..  p.  075): 
"Quaedam  dicuntur  ex  casu  al)st'rvata  fnisse.  ut  suffusos  i»ungere.  inde  quod 
capra  (luaepi-'i"'  t'>^  suffusione  male  liabens.  Jiinco  Mciileati)  in  octilum  impacto, 
visum  receperit."  Here  a  cataract  operation  is  spolien  of.  and  since  we  do  not 
possess  any  positive  evidence  that  any  operation  other  tlian  depression  was 
known  during  the  time  of  Galen,  hence  we  may  apply  these  remarks  directly 
to  the  operation  of  reclination.  It  is  perfectly  natural  that  such  an  operation 
should  have  been  made,  and  by  this  means  the  reasons  on  which  the  operation 
of  discission  is  based  were  finally  arrived  at.  It  must  certainly  strike  every 
one  as  a  curious  fact,  that  the  ancients  who  displayed  siuli  great  talent  in 
making  observations,  and  vrho  had  every  opportunity  of  observing  the  fre- 
quently occurring  cases  of  traumatic  cataract,  slioidd  not  iiave  come  upon  the 
idea  of  purposely  bringing  about  the  process  of  spontaneous  resorption  as  it 
occurs  in  traumatic  cataract.  However,  this  is  easily  explained  if  we  will  call 
to  mind,  that  in  most  of  the  cases  of  cataract  in  which  reclination  was  practiced, 
the  cataract  only  becaaie  partially  resorbed,  and  in  many  cases  of  reclination 
vision  was  restored  only  after  the  remains  of  the  lens  wliicli  occupied  the  pu- 
pillary area  were  gradually  resorbed.  and  that  frequently,  instead  of  making 
a  reclination.  in  reality  a  discission  was  made.     (See  Celsius.) 

I  can  not  refrain  from  again  most  particularly  drawing  attention  to  the  fact, 
that  this  book  is  only  ascribed  to  Galen;  the  period  when  it  was  written  is  not 
fixed.  I  also  desire  to  quote  a  passage  from  Aelian.2  which  has  been  translated 
by  Schneider:  "Caliginem  oculorum.  quam  suffusionem  medici  vocant.  caprinum 
pecus  probe  curare  scit;  et  ab  ipsa  remedium  ejusdem  homines  quoque  mutati 
dicuntur,  idque  hujusmodi  est.  Cum  conturbatum  oculum  sentit.  cam  ad  rubi 
spinam  et  admovet,  et  reserandam  permittit:  haes  ut  pupugit.  i)ituita  statim 
evocatur,  nuUaque  pupillae  laesione  facta,  viveudi  usum  recuperat:  neque  sane 
hominuum  sapientia  adfaciendam  sibi  meilicinam  egel."  Tliis  sliows  tliat  the 
fable  has  been  perfected  pretty  well. 

According  to  Scott.3  the  Brahmids  of  East  India  depressed  the  cataract  by 
means  of  a  small  cotton  tipped  probe,  which  is  inserted  through  an  opening  in 
the  sclera,  after  a  considerable  amount  of  the  vitreous  had  been  evacuated. 


2  De  Natura  Animalium.  Lib.  VII.  Cap.  14.     Ed.  Sdineider.     Leipsig.  1784. 
p.  230. 

3  Journal  of  Sciences  and   Arts.    Tendon.   ISIG.     No.   3.    pi.   II.   A.   B..   and 
Himly's  Krankheiten  und  Missbildungen,  Bd.  II.  p.  297. 


270 

According  to  Engel  4  the  same  procedure  is  successfully  practiced  in  Turkey, 
the  Moldan  and  AA^allaehei  of  Laien  (Stellwag,  1.  c.  1,  p.  771).  The  reports  de- 
serve to  be  recorded  here,  not  only  because,  as  Stellwag  has  pointed  out,  they 
teach  us  how  mucli  an  eye  can  withstand  without  being  totally  destroyed,  but 
because  they  teach  us  that  in  every  country  the  autochthon  cataract  operation 
was  the  depressio  cataractue  in  some  modified  form. 

B. 

EXTE ACTIO  CATAEACTAE. 

(PEE  KEEATOTOMIAM  AUT  PEE  SCLEEOTOTOMIAM). 

"Extraction"  was  the  expression  used  to  designate  every  operative 
metliod,  by  means  of  which  a  lens  of  normal  size,  shrunken,  transparent  or 
opaque,  with  or  without  its  capsule,  was  entirely  or  partially  removed  from 
the  eye  through  an  incised  or  thrust  wound  through  the  outer  coats  of  the 
eye,  (cornea  and  sclera)  and  through  the  (anterior  or  posterior)  capsule, 
proportionate  to  the  size  and  consistence  of  the  crystalline  body  or  portion 
of  the  same  to  be  removed.  According  to  the  position  of  the  incision,  the 
differentiation  was  established  between  a  corneal,  a  scleral,  and  a  corneo- 
scleral extraction,  and  depending  on  the  form  of  the  incision,  as  a  flap,  semi- 
circular (Bogen)  and  linear  extraction. 

"As  a  rule,  extraction  is  only  practiced  wliere  we  desire  to  remove  a  cata- 
ractous  lens  from  the  eye.  In  moi-e  recent  times  we  have  extracted  perfectly 
clear  lenses  where  particular  indications  presented  themselves,  as  where  sym- 
pathetic opthalmia  of  the  second  eye  had  set  in  (obsolete),  or  where  we  desire 
to  reach  a  cysticercus  in  the  vitreous,  or  behind  the  retina.  And  finally  it  has 
been  suggested  that  we  i-emove  a  normal  lens  to  overcome  a  high  degree  of 
myopia,  (Bonders.  1.  c.  p.  351).     (Fukula.4a) 

To  make  an  extraction  by  means  of  an  incision  behind  the  ciliary  body,  as 
was  suggested  and  often  practiced  by  Freitag,  Bell,  Butter,  Earlie  (263),  Quadii, 
Loebenstein-Loebell  and  Ritterich,  has  been  entirely  abandoned,  so  that  I  need 
pay  no  further  attention  to  this  procedure.  However,  in  the  last  few  years 
(1876)  this  scleral  incision  has  again  come  into  vogue,  in  removing  foreign 
bodies  from  the  vitreous,  also  subretinal  cysticercii;  hence,  this  scleral  incision 
is  at  least  worthy  of  being  mentioned  at  this  place.5  It  is  not  at  all  improbable 
that  the  operation  of  extraction  was  known  to  the  ancients.  Tlie  passage 
quoted  from  Plinius  (1.  c,  XXIX,  1,  8)  to  sustain  this  assertion,  reads  as  follows: 

"Ne  avaritiam  quidem  arguam,  rapacesque  nundinas  pendentibus  fatis.  et 
dolorum  indicaturam.  ac  mortio  arrham.  aul  iinaiia  itraeceptii.  S(|uamani  in 
oculis  emovendam  jxtlius  (piam  extraliend.-un:  per  (lu.ic  rtfCctiiiii   est.   ut  iiiliil 

4Gaz.  Med.  de  Paris,  1S4(). 

4a  Operative  Hcliandluiig  iKtclistgradiger  Myopic  durch  .\phakie.  Graefe's 
Arch..  Vol.  XXXVI.  2  P..  p.  2.",().     1800. 

5  See  O.  Becker,  in  Mauther's  Opthalmoskopie,  p.  467-4()8. 


271 

magis  prodosso  vidci-ctui-.  (|u;iiii  iiiuhiliiilo  .i;r:iss;iiiliiiiii.  NCipir  iiiiiii  pudor, 
sed  at'inuli  i>r('ti:i  sniimiit  t  mil."  I'.ut  tlicrc  is  imtliinu-  lo  show  ili.-it  the  word 
"squama,"  as  used  by  the  aiiciciits,  was  iist-d  to  dcsii^'nati-  a  cataract  (S.  Hirseh., 
p.  285).  Then  Galou  woidd  lie  the  liist  in  whoso  works  I  liiid  tiic  extraction 
mentioned.  In  "Methodi  Medendi,  l.XIA',  c.  13,  Ed.  Kuhn.  Tom.  X,  p.  986,"  Is 
written:  "  "'Efinalw  rV  loi;  I-tt)  tuv  rnoxofinrM'  (iTTmr'tTTTnvTEC  riw  np('.)Tov  OKorror  ffpof  FTcpov  ayo/iev 
al'T(i  rii-oi-  nKvpuTEpni'.      'Kvioi  (U  Kai  Tavrn  kfvoih'  tTrtXEipV^nv,  (jf  Iv  ro7f  jfy/joiy^yojyuvo/f  t/KJ." 

"The  extraction  is  again  mentioned  in  the  Continens  of  Rhazes,  who  lived  in 
the  ninth  century.  In  tlio  Venetian  edition  of  150<>  (Lib.  II,  Fol.  3,  B.  40),  we 
find  in  'Latyrion  dixit  cum  chiruigicus  vult  extrahere  cataractam  ferro  debemus 
tenere  instrumentuni  super  cataractam  per  magna m  horam  in  loco  ubi  ponitur 
illud,'  and  at  another  place  far  from  this  one  we  tiud:  'Dixit  Antilus  et  aliqui 
opererunt  sub  pupilla.et  extraxerunt  cataractam  et  potest  esse  cum  cataracta  est 
subtilius;  et  cum  est  grossa,  non  potnet  extrahi,  qui  humor  egrederetur  cum  ea.' 
Both  of  these  passages,  since  their  discovery  by  Albr.echt  von  Haller,  have  been 
quoted  in  all  text-books,  and  have  given  rise  to  a  great  many  false  conceptions, 
in  that  they  have  led  us  to  arbitrarily  place  the  time  of  Latryion's  life  in  the 
first  century  after  Christ;  whereas,  tlie  text  simply  states  that  he  must  have 
lived  before  the  ninth  century,  and  we  have  likewise  brought  Latryion  in  per- 
sonal relationship  with  Antilus,  Avho  lived  in  the  third  or  the  beginning  of  the 
fourth  century."    (Hirseh.) 

In  the  eleventh  century,  it  is  Avicenna  g  wlio  again  takes  up  tlio  subject  of 
extraction.  "There  are  various  instrumental  methods  of  treating  cataract,  thus 
there  is  one  iu  which  we  sever  the  lower  portion  of  the  cornea,  and  then  pull  out 
the  cataract;  but  this  is  dangerous,  for  with  the  cataract,  if  it  is  thick,  (agua 
quado  est  grossa),  the  vitreous  also  escapes."  It  is  worthy  of  note,  and  Hirseh 
drew  attention  to  it,  that  there  is  not  a  single  passage  extant,  which  could 
prove  to  us  that  any  one  of  the  well-known  ancient  physcians  ever  really  made 
an  extraction.  All  reports,  taken  from  that  time  forward,  and  on  which  any 
reliance  can  be  placed,  simply  go  to  show,  that  the  cases  which  they  report  are 
simply  hearsay,  and  others  coming  after  tliem,  have  simply  quoted  their 
writings. 

Avenzor,  who  lived  in  the  twelfth  century,  mentioned  the  extraction,  but 
declares  that  it  is  a  simple  impossibility.  He  writes  (Lib.  I,  Tract  8,  Cap.  19, 
Fol.  149):  "The  cataract  must  not  be  pulled  oiit  until  it  is  fully  ripe;  if  removed 
sooner  it  will  return,  .  And  when  I  say  pulled  out  (extrahere),  I  desire  you  to 
understand  that  this  is  not  possible,  as  so  many  believe,  but  that  I  push  the 
.cataract  down  into  the  depths  of  the  eye  by  means  of  a  needle,  and  when  I 
have  done  this  I  draw  the  needle  out  again." 

All  other  evidence  of  ancient  times  and  tlie  middle  ages  is  not  relevant  to 
the  operation  of  extraction.  From  the  time  of  Avenzor  until  the  close  of  the 
seventeenth  century,  all  writers  are  so  completely  silent  on  this  subject  that 
we  must  come  to  the  conclusion  that  it  had  fallen  entirely  into  oblivion.   Hence, 


6  Ed.  Venetio,  1544,  Fol.  237.  Buch  3,  Fen.  3,  Tract  4,  Cap.  20. 


272 

we  are  placed  in  a  position  wliere  we  can  follow  closely,  even  in  its  preparatory 
stages,  the  discovery  of  the  corneal  extraction  by  Davlel.  In  his  dissertation 
(De  Cataracta  Argentorum).  which  appeared  in  1721,  Henrieus  Freitag  tells 
us,  that  in  1G94  his  father,  John  Conrad  Freitag,  removed  through  the  sclerotic. 
by  means  of  a  hook-shaped  needle,  two  cataracts  which  had  again  "risen  up" 
after  reclination.  According  to  the  statements  of  Albini.  in  Goskey's  disserta- 
tion (15),  about  this  time,  in  1695,  men  traveled  from  place  to  place  (cataract 
cutters— staarstecher)  who  practiced  extraction  through  the  cornea.  Gosky 
described  an  instrument  something  like  a  pair  of  forceps,  which  was  used  to 
extract  the  grey  cataract.  He  gives  an  illustration  of  this  instrument  in  his 
dissertation. 

These  facts  were  unknown  to  the  French,  to  whom  we  are  really  indebted 
for  the  method  of  extraction.  At  the  same  time  that  Brisseau  made  his  dis- 
covery as  to  the  seat  of  cataract,  St.  Yves  (1707),  Du  Petit  (1708)  and  Duddell 
(1729),  extracted,  per  corneal  incision,  cataracts  which  had  fallen  into  the  an- 
terior chamber  during  reclination. 

In  1745  Jacques  Daviel  found  himself  called  upon  to  practice  this  same 
procedure  which  Petit  had  practiced,  being  compelled  to  remove,  per  corneal 
incision,  a  cataract  which  liad  fallen  into  the  anterior  chamber  while  making 
a  reclination. 

Jacques  Daviel  was  born  in  La  Barre.  Normandy.  August  11,  1696.  He 
studied  at  Rouen,  and  served  at  the  Hotel  Dieu,  in  Paris.  In  1719  he  was  sent 
as  "plague  physician"  to  Provence,  and  for  the  services  there  rendered  he  was 
appointed  Surgeon  to  the  City  of  Marseilles.  There  he  became  Professor  of 
Anatomy  and  Surgery,  but  from  1728  he  employed  his  time  exclusively  in  the 
treatment  of  eye  diseases,  ^nd  he  became  so  renowned  that  he  was  repeatedly 
called  to  Portugal  and  to  Italy.  In  1746  he  settled  in  Paris,  and  in  1749  he 
received  the  appointment  of  Surgeon  Oculist  to  the  King.  In  1750  he  was 
called  to  attend  the  Kurfurstin  at  Mannheim;  in  1754  to  Ferdinand  VI.  of  Spain, 
and  later  he  was  once  more  called  to  see  the  Princess  Clemens  of  Bavaria. 
To  restore  his  shattered  health  he  went  to  Bourbon  and  to  Geneva,  to  take  the 
baths,  at  which  latter  place  he  died  in  1762. 

A  hermit  of  Aiguilles,  in  Provence,  was  operated  on  the  right  eye  without 
result,  and  came  to  Marseilles,  where  Daviel  was  at  that  time  residing,  to  be 
operated  on  his  left  eye  by  him.  But  Daviel  had  no  greater  success.  A  num- 
ber of  pieces  of  tlie  lens  fell  into  the  .'interior  chnuilx'r.  whieli  :il  the  same  time 
became  filled  witli  blood.  Daviel  then  punctured  the  cornea  Avith  a  bent  needle, 
and  enlai'ged  the  opening  with  a  pair  of  curved  scissors.  The  pupil  cleared  up 
and  the  patient  saw.  Two  days  later,  however,  purulent  iutlammation  set  in. 
and  the  eye  was  lost.  Nevertheless.  Daviel  advanced  a  step  farther,  and  made 
the  attempt  to  reach  the  lens  in  its  capsule  by  inc-ins  of  an  incision  in  the 
cornea,  and  then  to  permit  the  lens  to  enter  \Uv  miterior  chamber  through  the 
pupil,  and  from  here  to  draw  (tirer)  it  out  of  the  eyi".  He  did  this  operation 
the  first  time  on  a  woman.     He  tells  us:    ".louveris  la  <-ornt'e  coniuie  .ie  I'ai  ex- 


273 
pliqiu'  cusuito  fii  i)()rl:ni1  la  iM'til  spamlr  <l..ut  J  ai  d.-Ja  iiail.'  siir  la  iiarti.-  siipe- 
rieure  de  la  cataiacte  jo  la  detadiai  ct  je  la  tirai  on  inorceaux  hors  de  I'oell 
avec  cet  instrument.  La  prunelle  panit  nette.  la  malado  n'eut  la  raoindre  acci- 
dent, et  fut  guerie  guinze  jours  apres."  After  five  successful  operalions  he 
had  one  failure,  and  Daviel  decided  for  the  time  being  to  give  up  this  method, 
and  returned  to  reclination.  This  he  likewise  did  in  a  particular  manner,  in 
that  he  first  opened  the  sclerotic  at  the  usual  place  by  using  a  double  edged 
needle;  he  then  entered  with  a  blunt  instrument,  with  which  he  dislocated  the 
lens.  Two  years  later,  in  1747,  while  operating  a  gentleman  in  Paris,  to  which 
city  he  had  in  the  meantime  removed  his  residence,  he  was  again  compelled 
to  incise  the  cornea,  in  order  to  permit  the  cataract,  which  it  seems  would  not 
be  dislocated  into  the  vitreous,  to  escape  through  the  pupil  and  corneal  wound. 
Although  there  was  a  slight  loss  of  vitreous,  the  operation  was  followed  by  a 
successful  result.  From  now  on.  during  the  following  three  years,  he  from  time 
to  time  operated  through  the  cornea,  in  order  to  attain  greater  accuracy  in 
this  new  method  of  operating.  He  writes:  "Mais  ce  n'est  determinement  que 
dans  le  cours  du  voyage  que  jai  fait  a'  Mannheim  (1750).  poury  traiter,  S.  A.  S., 
Madame  La  Princesse  Palatine  de  Deuxponts.  d'une  ancienne  maladie  qu'elle 
avait  a  I'oeil  gauche,  que  je  pris  la  resolution  de  ne  plus  desormais  operer  la 
cataracte  que  par  extraction  du  cristallin." 

Regarding  this  operation,  which  he  made  at  Mannheim.  Remon  de  Vermale, 
Physician  to  the  Kurfstin,  made  a  report  in  a  letter  to  Mons.  Chicoyneau,  Pri- 
vate Physician  to  the  King  of  France,  and  later  in  a  copy  to  Van  Swieten,  Phy- 
sician to  Her  Royal  Highness  in  Vienna.  There  are,  all  told,  but  three  pure 
cataract  extractions.  They  were  made  respectively  on  '"The  Court  Officer, 
Schlemmer,  of  Mannheim,  aged  60  years;  on  "The  Master  of  the  Horse,"  of  the 
Margrave  of  Baden  Durbach,  Baron  v.  Beck,  aged  57,  and  on  the  journeyman 
tailor  and  drummer  of  the  town  of  Heidelberg,  Franz  Kertenayer.  These  three 
cases  are  of  historical  interest,  because  Vermale's  reports  are  the  first  literary 
evidence  we  possess  of  Daviel's  operation;  indeed,  of  the  flap  operation.  This 
letter  of  Vermale  is  dated  November  2.^1.  17.50,  and  it  seems  tliat  it  appeared  in 
print  in  Paris  as  his  own  pamphlet  in  1751.  Daviel  referred  to  this,  and  speaks 
of  it  as  a  dissertation  in  his  "Original  Investigations,"  which  he  presented  be- 
fore the  Academy.  "Sur  une  uouvelle  methode  de  uerir  la  cataracte  par  la 
extraction  du  cristallin  (107),  which  was  written  in  1752,  but  was  first  pub- 
lished in  17,53,  in  volume  II  of  Memoirs  de  I'Academie  de  Chirurgie.  (The  first 
volume  of  this  memoir  bears  the  date  of  1743).  To  this  fact  can  be  traced  the 
errors  which  arose  regarding  the  date  of  the  first  literary  reports  of  Daviel's 
extraction. 

Hirschberg7  claims  that  this  was  not  published  until  1757.  A  German 
translation  of  this  first  publication  of  Daviel's  appears  in  the  work  of  Magnus 
(1876,  p.  205).    Unfortunately  this  contains  an  ugly  error.     "The  cornea  is  cut 

7  H.  Archive,  p.  198.    1890.    Zur  Geschicte  der  Star  Auziehung. 


274 

in  the  shape  of  a  cross."  The  original  statement  is,  "in  the  shape  of  a  half 
moon."  From  the  time  of  Richter  (Gr.  Staar.  Goettinger,  1773)  up  to  the  pres- 
ent day,  all  writers  state  that  Daviel  cut  two-thirds  of  the  corneal  circumfer- 
ence.   Daviel.  however,  states  "only  a  little  more  than  half." 

The  idea  of  this  new  method  was  conceived  in  1745;  for  at  that  time  he 
extracted  a  cataract  which  \\  ms  still  in  position  behind  the  iris  and  still  enclosed 
within  its  capsule.  But  since  lie  emphatically  states  that  on  his  trip  to  Mann- 
heim he  made  up  his  mind  in  tlie  future  to  employ  exclusively  this  new 
method;  hence,  we  must  designate  the  year  17.jO  as  the  true  year  in  which 
this  method  of  extraction  was  born.  During  this  year  the  new  idea  received 
its  introduction  into  practical  existence. 

It  becomes  a  matter  of  special  interest,  as  can  be  seen  by  reviewing  Ver- 
male's  descriptions,  that  just  that  condition,  in  the  case  of  a  certain  Baron 
V.  Sickingen.  Lord  Steward  of  the  Elector,  Carl  Theodore,  which  lead  to  the 
painful  inflammation  from  which  he  suffered  for  years,  as  the  result  of  recli- 
nation,  and  to  relieve  which  the  most  renowned  German  oculists  had  been 
called  from  long  distances,  was  only  relieved  after  Daviel  had  extracted  the 
lens,  which  had  again  risen  iip.  This  circumstance  finally  Jead  Daviel  to  the 
determination  to  adopt  this  method  of  extraction,  and  it  is  this  danger  which 
arises  from  the  retention  of  a  cataract  within  the  eye,  which  in  our  day  has 
become  the  main  reason  for  our  almost  entirely  abandoning  this  operation  of 
reclination. 

.The  details  of  the  operation  have  naturally  been  greatly  changed  since 
Dayiel's.  time,  but  in, all  methods  of  extraction  the  main  idea  has  naturally 
been,  retained. 

Daviel  employed  an  instrument  which  corresponds  to  the  bent  lance  in  use 
today,  and  with  this  he  incised  the  lower  edge  of  the  cornea,  and  widened  the 
wound  to  the  right  and  to  the  left,  either  by  using  two  blunt  knives  (aiguille 
mousse),  or  by  using  a  pair  of  curved  scissors,  which  today  bear  Daviel's  name; 
so  that  about  the  lower  two-thirds  of  the  corneal  periphery  was  severed.  Daviel 
says:  "Et  Achevera  la  section  taut  d'un  cote  que  de  Tautre  afin  de  la  porter 
de  chaque  cote  un  pen  en  dessus  de  la  prunelle."  Aside  from  this,  we  can  get 
this  information  by  studying  his  Illustrations.  He  then  lifted  up  the  corneal 
flap  with  a  golden  spatula,  and  cut  the  anterior  capsule  Avlth  a  sharp  pointed 
needle.  Finally,  In  order  that  the  lens  might  escape,  he  pressed  on  the  lower 
portion  of  the  globe. 

The  cliangos  and  improvements  which  the  method  of  Daviel  under- 
went refer  partially  to  the  instruments  used,  partly  to  the  size,  form  and 
seat  of  tlie  wound. 

Just  as  we  find  it  true  in  general  siiroery.  so  also  will  we  find  that  the 
cleaner  cut  the  incision,  the  greater  will  he  the  tendency  to  heal.  On  this 
principle  must  have  been  based  the  idea,  which  led  Poyet  and  Dr.  La  Faye 
to  use  an  instrument  like  a  knife  in  cutting  the  cornea,  and  which  finally 


275 
led  to  the  construction  of  IJccr's  Ciit;ii-;ici  knife,  wliicli  is  lo  be  considered 
a  great  step  toward  advaiK  rnicni.  I'.y  iiMiins  of  Beci-'s  knife,  it  is  not  only 
possible,  but  it  is  customary,  to  uiakc  a  coiiiplcte  corneal  incision  by  a  single 
sweep  of  the  knife,  and  by  this  means,  in  tlie  great  majority  of  cases  it  is 
possible  to  get  a  surface  wound  which  lies  everywliere  on  an  equal  plane. 
For  the  same  reason,  the  use  of  a  (iraefe's  scleratome  must  be  looked  upon 
as  a  step  backward,  since  it  is  only  possible  in  exceptional  cases  to  make  the 
entire  incision  by  a  single  pass  of  the  knife.  As  a  result,  the  surface  of 
the  wound  lies  in  different  planes,  and  may  even  be  jagged  or  step-like. 
If,  notwithstanding  all  this,  the  scleratome  has  received  greater  recognition, 
this  surely  must  be  due  to  other  circiimstances;  more  especially  since  with 
it,  it  is  easier  to  make  a  conjunctival  flap. 

A  similar  view  has  been  promulgated  regarding  tbe  form  of  the  wound, 
which  during  the  first  hundred  years,  aside  from  the  reduction  of  the  in- 
cision, from  two-thirds  to  one-half  of  the  base  of  the  cornea  had  been  but 
slightly  changed,  whereas  since  1850,  especially  as  the  result  of  the  efforts 
of  Ton  Crraefe  and  his  pupils  this  has  been  materially  changed.  (III..  1., 
p.  291).  The  peripheral  linear  incision  is  to  be  praised  as  an  advancement, 
owing  to  its  tendency  to  heal;  the  height  of  the  flap  is  lessened,  the  wound 
is  made  in  such  a  place  which  is  at  least  partially  permeated  by  blood  vessels, 
and  in  the  conjunctival  flap  was  attained  a  sort  of  provisional  bandage  and 
protection  against  infected  conjunctival  secretion.  However,  it  can  not  be 
denied  that  the  necessity  of  the  iridectoraie  lengthens  the  time  of  the  opera- 
tion and  can  not  but  be  looked  upon  as  detrimental,  as  must  also  be  the 
12-15  mm.  in  length  wound  of  the  iris,  such  as  has  heretofore  been  made. 

Though  the  majority  of  operators  accept  the  wound  of  the  iris  as  a 
part  of  the  operation,  this  fact  does  not  settle  the  question  as  to  whether 
the  wound  of  the  iris  is  of  a  more  trivial  nature,  than  the  distension  and 
squeezing  to  which  the  iris  is  subjected  when  a  flap  extraction  is  made 
without  an  iridectomie.  but  it  rather  points  to  the  fact,  that  in  the  old  flap 
extraction  it  is  more  difficult  to  cause  the  lens  to  come  out  of  a  corneal 
wound  of  the  proper  size,  where  the  capsule  of  the  lens  has  been  opened 
to  a  sufficient  extent,  and  where  all  superfluous  pressure  is  avoided  during 
the  delivery  of  the  lens,  and  at  the  same  time  cause  but  a  minimum  insult 
to  the  iris.  The  complicated  effect  of  a  large  iris  wound  can  be  overcome 
by  making  the  iridectomie  several  weeks  before  the  extraction.  (Mooren). 
Undoubtedly  the  extraction  wound  will  tlieii  He  partially  in  the  corneal 
cicatrix  of  the  iridectomie  incision.  A  priori,  one  would  imagine  that  here 
would  be  developed  a  condition  which  would  not  be  favorable  to  the  heal- 
ing process.  This,  however,  is  rebuted  by  the  results  obtained  by  numbers 
of  operators,  who  always  make  a  preliminary  iridectomie,  and  have  had  uni- 


276 

formly  good  results.  The  main  advantages  to  be  derived  from  a  prelim- 
inary irideetomie  previous  to  the  delivery  of  the  lens,  is  to  be  found  in  the 
ease  and  certainty  with  which  cataractous  remains  behind  the  iris  may  be 
completely  removed  from  the  eye  by  shoving,  stroking  and  pushing  maneu- 
vers; much  more  so  than  is  possible  with  a  coloboma  of  the  iris.  The  form 
of  the  crystalline  pearls  which  remain,  depends  largely  on  the  operative 
method  employed.  In  all  the  various  methods  mentioned,  in  the  most  suc- 
cessful cases,  all  that  can  take  place,  is  a  complete  evacuation  of  the  lens 
substance.  On  the  other  hand,  the  retention  of  the  capsule  in  the  eye 
makes  a  total  evacuation  of  cortical  remains  all  the  more  difficult.  Those 
portions  located  in  the  equatorial  region  lie,  as  it  were,  in  a  pocket,  and 
although  they  may  get  in  the  area  of  the  coloboma  and  be  visible  to  the  naked 
eye,  they  can  not  be  removed,  notwithstanding  every  effort.  Hence  one 
can  comprehend  why,  since  Daviel's  time,  the  quest  for  an  operative  pro- 
cedure, by  means  of  which  it  would  become  possible  to  remove  a  cataract, 
together  with  its  capsule,  has  never  ceased.^  Pagenstecher,  following  this 
line  of  thought,  has  been  quite  successful.  It  becomes  self-evident  that 
if  a  method  should  ever  be  discovered,  by  means  of  which  it  would  become 
possible  in  evety  case  to  remove  a  cataract  in  its  capsule,  without  at  the 
same  time  more  seriously  in juTing- the  eye  than  is  done  at  the  present  time, 
or  if  it  should  ever  become  possible  to  perfect  our  powers  of  diagnosis  to 
such  degree  as  to  determine  if  it  would  be  possible  to  make  an  extraction  in 
the  capsule,  such  a  method  would  in  all  time  to  come,  take  first  rank  as  an 
operative  procedure  in  opthalmology. 

In  1886,  Prof.  Hirschberg,  of  Berlin,^  published  a  paper,  in  which 
he  describes  the  essential  differences  between  the  various  operations  and  the 
causes  which  led  up  to  their  use.  He  draws  attention,  as  does  also  Jacob- 
son,^^  to  the  jealousy  which  has  been  engendered  between  the  French  and 
the  German  oculists  as  to  the  relative  value  of  the  operations  introduced 
respectively  by  Daviel  and  Von  Graefe. 

Jacobson  states,  "In  order  that  I  may  add  something  to  the  history  of 
the  past  twenty-five  years,  I  will  tell  my  colleagues  what  the  attitude  of 
"Von  Graefe  toward  Daviel's  extraction  was.  Forty  years  ago,  (1846),  when 
but  few  extractions  were  made  in  Berlin,  and  Junken,  as  the  knight  of  the 
needle,  dazzled  large  audiences  with  his  recital  of  the  surprising  indica- 
tions for  reclination,  depressio,  sublatio,  etc.,  the  teachings  of  the,  at  that 
time,  illustrious  artist,  did  not  impress  Von  Graefe  in  the  least.    After  he 

8  Graefe  Saemiscb.  Vol.  Ill,  p.  284. 

9  Uber  Stnaroperationei).     Deutsche  Med.  Wochenschrift.  p.  410. 

10  Ein    Motivirtes    I'rtheil    uber   Daviel's    liappen    Extraction    und   Graefe's 
Linear  Extraction.   Yon  Prof.  J.  Jacobson.  in  Konigsberg.   Graefe  Arcb.  1886. 


277 
had  finished  his  studies  in  I'aris,  Prague  and  N'ienna,  he  began,  in  1854,  to 
teach,  what  to  him  seemed  the  only  justifiable  operation  for  senile  cataract, 
and  that  reclination  was  only  to  be  practiced  in  exceptional  cases,  as  where 
the  first  eye  had  been  lost  by  purulent  inflammation.  Jacobson  tells  us  that 
lie  first  made  Yon  Graefe's  acquaintance  at  a  time  wlien  he 
was  an  enthusiastic  follower  of  the  French  method,  and  during  winch 
time  reclination  was  still  being  actively  employed  in  I'aris  and  in  the 
Austrian  Universities.  He  devoted  the  greatest  care  to  the  preparatory 
treatment,  the  various  forms  of  dressing,  and  to  the  after-treatment,  but  he 
tried  everything  in  vain.  That,  which  his  teachers  experienced,  he  was 
not  spared,  about  10  })er  cent,  of  his  cases  were  lost  as  the  result  of  corneal 
ulceration.  From  that  time  on,  his  every  endeavor  tvas  to  prevent  suppura- 
tion:' 

Hirschberg  tells  us,  that  the  original  Daviel  incision,  made  in  the  first 
half  of  the  present  century,  was  a  lower  half-circular  incision  made  in  the 
corneal  lissne,  close  to  its  margin.  (According  to  Kichter,  one-half;  Beer, 
one-eighth;  Arlt,  one-half  mm,  from  the  limbus;  whereas  Young's  incision 
was  a  good  2  mm.  from  the  corneal  margin,  hence  the  opening  was  often 
too  small,  and  at  times  he  failed  to  deliver  the  lens). 

We  are  indebted  to  the  illustrious  men,  Beranger,  Wenzel,  G.  A. 
Eichter,  and  Beer,  for  the  perfection  of  the  flap  operation,  which  today,  as 
the  classical,  is  compared  with  the  so-called  Yon  Graefe,  or  modern,  opera- 
tion. As  a  fact,  a  perfect  flap  extraction  belongs  to  the  most  beautiful 
surgical  procedures.  The  cicatrix  is  scarcely  visible  to  the  naked  eye, 
scarcely  more  noticeable  than  the  ordinary  senile  change.  The  pupil  is 
round,  and  reacts;  at  most,  the  iris  may  be  somewhat  displaced  backward, 
owing  to  the  absence  of  the  lens,  and  by  the  use  of  proper  cataract  glasses, 
vision  is  excellent.  But  this  ideal  result  was  attained  in  but  50  per  cent, 
of  cases,  and  even  in  the  hands  of  the  best  operators,  purulent  destruction 
followed  in  at  least  10  per  cent,  of  cases.  Still  no  one  dared  to  make  the 
incision  smaller.  This  had  long  been  looked  upon  as  a  great  mistake 
and  source  of  loss.  At  this  time,  Graefe  appeared  upon  the  scene.  After 
a  series  of  attempts  made  by  himself  and  his  pupils,  especially  Mooren,  in 
Dusseldorf,  Yon  Graefe  introduced  the  preparatory  iridectomie  in  1864, 
and  Mooren  reduced  his  percentage  of  losses  from  11  per  cent,  down  to  3i 
per  cent.  In  1863,  Jacobson,  of  Konigsberg,  made  his  incision  in  the  sclero- 
corneal  margin,  to  which  he  now  added  the  iridectomie  under  deep  chloro- 
form narcosis,  and  thus,  in  100  cases,  reduced  his  losses  from  10  per  cent, 
down  to  2  per  cent.  In  1864,  Bowman  and  Critchett.  of  London,  accepted 
Graefe's  modified  linear  extraction,  (incision  witli  a  lance  knife,  above;  ex- 
cision of  iris,  and  delivery  of  the  lens  with  a  spoon),  and,  finally,  in  1866. 
Von  Graefe  published  his  "Peripheral  Linear  Incision/'  which  was  looked 


278 

upon  as  a  great  triumph,  and  won  the  admiration  of  the  opthalmologists 
of  the  entire  world.  "I  shall  never  forget  how,  in  18(5;,  oplhalmologists 
from  every  part  of  the  civilized  world  flocked  to  Berlin,  to  see  with  their 
own  eyes  this  new  method.  The  Opthalmological  Congress  at  Paris  in 
1867,  and  Heidelberg  in  1868,  bronght  endless  words  of  praise  from  Arlt, 
Knapp,  Rothmund,  Horing,  Nagel,  Horner,  Critchett,  Soelberg-Wells,  Ed. 
Meyer,  Wecker,  and,  what  seems  more  especially  noteworthy,  from  Mooren, 
and  Jacobson,  (Arch.  f.  Opth.,  XIV.,  1868).  who  preferred  this  operation 
to  his  own." 

Albrecht  Von  Graefe  struck  the  proper  chord,  when  he  attempted  to 
prevent  the  unnecessary  gaping  of  the  corneal  wound.  He  asked  himself, 
what,  in  the  eye,  is  the  analogous  condition  to  a  linear  incision,  and  he  rec- 
ognized the  fact,  that  on  a  globe  the  shortest  distance  between  two  points 
is  along  a  segment  of  the  greater  circle  of  a  sphere,  and  he  accomplished 
this  by  the  narrow  hiife  devised  hij  himself.  This  incision  just  cut  the 
upper  corneal  margin.  It  was  a  linear  incision  4^  mm.  long,  to  cover  which 
he  also  cut  a  narrow  strip  of  ocular  conjunctiva;  he  then  exercised  a  sector 
of  the  iris,  opened  the  capsule  with  a  small  curved  cystitome,  and  he  re- 
moved the  lens  by  soft  massage  from  without,  made  by  means  of  a  rubber 
spoon  on  the  lower  edge  of  the  cornea.  This  operation,  as  a  rule,  was  done 
without  an  anaesthetic;  the  four  acts  of  the  operation  being  done  while  the 
eyeball  was  fixed.    At  times  the  English  speculum  was  used. 

It  can  not  be  denied,  that  this  operation  reduced  the  percentage  of 
losses  from  10  per  cent,  to  5  per  cent.,  and  losses  by  suppuration  were  re- 
duced to  2-3  per  cent. 

A.  V.  Graefe,  in  'M9  extractions  had  3.3  per  cent.  loss. 

Mooren,  in  102  extractions  had  2.9  per  cent.  loss. 

Knapp,  in  200  extractions  had  2.0  per  cent.  loss. 

Arlt,  in  217  extractions  had  6.5  per  cent  loss. 

Arlt,  186(i-73,  in  1075  extractions  had  5.6  per  cent.  loss. 

Arlt,  1874-81,  in  1547  extractions  had  2.06  per  cent.  loss. 

Horner,  in  1(X)  extractions  had  3.0  per  cent.  loss. 

Rothmund,  in  186  extractions  had  3.8  per  cent.  loss. 

Rothmund,  1869-83,  in  1420  extractions  had  4.2  per  cent.  loss. 

Possibly,  the  only  one  who  did  not  follow  the  new  operation  was  Has- 
ner,  of  Prague.  He  had  an  exceedingly  large  experience — 6-7,000  extrac- 
tions— and  he  always  made  the  half-circle  incision. 

(  Nagel's  Bkrichtk.  ) 

1868—106  flap  extractions,  only  4  per  cent  loss. 

1877—138  flap  extractions,  121  good  results,  12  medium,  3.6  per  cent.  loss. 

1879—131  flap  extractions,  85.5  percent,  good  results,  10.7  per  cent,  medium,  3.8 
per  cent.  loss. 

1880—110  flap  extractions,  85.4  per  cent,  good  results,  9.9  per  cent,  medium,  6.36 
per  cent.  loss. 


279 

-But  scarci'ly  was  llic  lioii  dca'l.  iliaii  an  oi.po.Hlioii  dcvi'lnprd.  whicli 
formerly  did  not  i)oss("ss  tlic  conra.iic  to  assert  itself.  Ten  years  after  the 
introduction  of  the  Von  (iraefe  nietho.l  the  >iateineiit  i^  made,  thai  imlliine 
remains  J.vt  the  knife." 

(iraefe's  life  ha.s  borne  fruit  tn  the  eatai-act  (iperation.  and  certainly 
has  led  to  the  develoi)ment  of  new  ideas.  His  metho.l  reduced  the  percent- 
age of  losses,  even  in  the  hands  of  those  who  have  >inee  changed  his  tech- 
nique. His  intlnenee  may  l)e  com[)ared  to  that  of  J.ister,  \vho.se  fame  will 
live  on.  h)ng  aftei-  his  iiK'as  liave  been  set  aside  hy  the  advancement  of 
science.  True,  time  has  shown  that  the  principle  of  the  linear  incision  is 
not  as  essential  as- Yon  Graefe  originally  thought.  Where  not  accurately 
made,  the  linear  incision  is  often  too  small,  and  places  difficulties  in  the 
way  of  the  deHvery  of  the  lens,  and  leads  to  escape  of  vitreous.  In  the 
hands  of  a  novice  the  linear  incision  may  he  too  peripheric, .and  as  a  con- 
sequence leads  to  cicatrization  of  the  iris  in  the  wound,  and  this  to  sympa- 
thetic o])thalmia — an  almost  unheard-of  complication  during  the  time  of 
the  classical  flap  operation. 

The  new  method  had  the  advantage,  that  the  U'lis  no  longer  had  to  be 
forced  through  a  small — in  old  people,  often  rigid — sphincter,  which  can 
scarcely  be  dilated,  and  which  now  could  easily  come  forward  through  the 
sht  in  the  iris,  and.  further,  that  cortical  remains  could  easily  be  removed 
by  simple  massage  without  going  into  the  eye  with  a  spoon. 

And  thus  a  sort  of  compromise  procedure  has  developed,  which  bears 
the  name  of  no  operator,  which  is  very  like  the  Graefe  procedure;  has  ac- 
cepted all  its  advantages,  and  tries  to  avoid  all  the  recognized  dangers,  and 
has  received  the  name  of  the  one-thixd  circumference  incision}^  The  incision 
should  always  be  of  sufficient  size  to  permit  the  largest  lens  system,  though 
it  be  hard. 'to  pass  easily.  This  can  he  done  where  the  incision  equals  one- 
third  of  the  corneal  circumference.  In  the  centre  of  the  incision  a  section  of 
the  iris  is  removed,  then  the  cystotomie  and  delivery  of  the  lens  follows  by 
simply  applying  moderate  pressure  to  the  lower  part  of  the  cornea. 

Jacobson  (cited  above)  sums  up  the  subject  with  the  statement  that  a 
great  many  opthalmologists  have  gone  over  from  the  Graefe  operation  to 
the  peripheric  ftap  incision  in  the  corneal  margin — hut  not  to  the  Dariel  fiap. 
So  that  the  incision  is  the  one  originall  suggested  by  Jacobson  in  1863.  He 
states:  '".-l  large  incision  in  /lie  si  Irm-cornenl  man/in  heats  l)elter  than  a 
Daviel's  flap  or  the  so-called  lornenl  linear  Imision. 

niDDe  Wecker— Annales  d  Oculistiquo.  1884.  92.  p.  207.  and  188.1.  p.  29. 
(2)  Hirschbers's  Deutsche  Zeitsclirift  fur  IMak.  Med.  1887.  Beitrag  zur  Augen- 
beilkunde  Heft.,  HI.  1878.  p.  77. 


28o 

Jacobson  summarizes  the  value  of  both  Von  (Iraefe's  and  Daviel's  work, 
as  follows: 

*'It  will  always  remain  as  the  undeniable  work  of  Von  Graefe,  that  he 
did  not,  as  most  of  his  predecessors,  content  himself  with  attempts 
to  stop  suppuration  of  the  cornea,  but  after  long  and  systematic  attempts, 
became  the  originator  of  a  new  method  of  extraction,  in  which  the  dangers 
of  wound  infection  were  reduced  to  a  minimum.  Though  the  theoretical 
premises  may  have  been  ever  so  wrong,  still,  as  a  result  of  this  method  of 
extraction,  losses  by  suppuration  were  reduced  from  10  and  12  per  cent, 
down  to  3  and  4  per  cent.,  and  poor  results  from  10  or  15  per  cent,  to  about 
6  per  cent." 

"To  Daviel  belongs  the  honor  of  having  devised  the  bold  procedure,  by 
means  of  which  all  the  forms  of  later  times  have  been  made  possible,  and 
which  totally  set  aside  reclination,  depression,  and  simiiaf'  methods,  which 
in  their  old  form  will  never  return.  It  is  not  the  great  practical  service 
of  having  reduced  the  25  per  cent,  of  losses  down  to  10  or  12  per  cent., 
which  will  make  Daviel's  name  immortal  in  the  history  of  our  science,  but 
rather  his  clear  insight,  which  showed  him  the  way  to  the  only  safe  means 
of  extracting  the  cataract  from  the  eye,  and  to  a  perfect  method  of  healing. 
His  boldness,  which  permitted  him  to  make  such  an  extended  separation  of 
the  cornea  without  fear  of  injury  to  the  eye,  his  great  surgical  genius,  which 
lead  him  to  devise  from  its  very  beginning  the  compKcated  technique  of 
this  operation,  all  pronounce  him  the  father  of  this  operation,  whereas  to 
Von  Graefe  belongs  the  credit  of  having  removed  its  most  serious  dangers 
by  means  of  his  new  operation." 

C. 
DISCISSIO  CATAEACTAE.    BROIMENT  DE  LA  CATARACTE. 

DISCISSIO  CATAEACTAE  PEE  KEEATONYXIM  AUT  PEE  SCLEE- 
OTICONYXIM. 

Where  a  discission  is  made,  {discissio  capsulae  Icntis,  incising  of  the 
capsule),  the  intention  is,  by  means  of  a  needle,  which  is  pushed  through 
the  cornea  or  sclera,  to  open  the  anterior,  also  the  posterior  capsule,  so  as 
to  bring  the  lens  substance  in  direct  contact  with  the  aqueous  humor,  or 
the  vitreous,  so  that  it  may  be  absorbed,  and  also  that  the  anterior  capsule 
may  draw  back  out  of  the  pupillary  area. 

"Discission  is  tlic  latest  of  the  three  principal  cataract  operations.  It  is 
also,  so  to  say.  a  daujiliter  of  depression.  Amonp  the  writings  of  the  ancients 
(Galeuus.  de  Methodis  Medendi.  XIV.  edition  Kuhn.  torn.  X.  p.  1019).  we  find 
but  a  single  passage  which  seems  to  refer  to  this  operation  of  discission.    The 


28l 

translation  of  this  passage,  wliidi  Aiia^xnostakis  (12MJM  made,  seems  to  liavo  been 
made  with  a  purpose.  Learned  philologists  whom  1  have  consulted  regard- 
ing this  passage  are  not  at  all  satisfied  with  his  translation.  The  whole  matter 
appears  to  have  reduced  itself  to  this,  namely;  and  this  we  also  Ijnow  from 
other  sources,  that  the  ancients  did  puncture  the  cornea.  Since  all  the  more 
exact  points  of  differential  diagnosis  were  wanting  for  all  those  diseases  which 
lead  to  a  cloudiness  posterior  to  the  pupil,  to  adhesions  and  indistinctness  of 
the  same,  I  am  no  longer  in  doubt,  after  a  somewhat  thorough  investigation  of 
the  literature  that  the  great  confusion  wliich  existed  concerning  these  named 
processes,  was  the  result  of  the  continual  confounding  of  glaucoma,  occlusion 
of  the  pupil,  and  liypopyon,  one  with  anotiier.  To  say  the  least,  it  would  be 
exceedingly  strange  if  discission  had  been  known  to  Galen,  and  that  the  knowl- 
edge of  this  would  have  been  completely  lost  again  for  hundreds  of  years." 

It  must  certainly  have  occurred  frequently  during  the  act  of  making 
a  depression;  and,  in  fact,  it  must  of  necessity  have  occurred  in  all 
cases  of  cataract,  that  large  portions  of  the  same  strayed  into  the  pupillary 
area  and  protruded  into  the  anterior  chamber,  or  remained  in  the  patellar 
fossa  or  in  the  vitreous  itself.  Even  in  Malgaigne's  time,  where  contro- 
versies concerning  the  existence  of  capsular  cataract  were  going  on,  such 
remains  of  lens  substance  were  looked  upon  as  pieces  of  thickened  capsule. 
But  from  these  numerous  clinical  histories,  in  which  we  find  such  accurate 
descriptions  of  how  these  capsules  were  gradually  absorbed,  it  fdllows,  that 
they  could  only  have  been  remains  of  lens  substance.  Henkel  (1770)  was 
the  first,  to  whom  this  common  occurrence  suggested  the  founding  of  a 
new  operative  procedure.  The  statements  of  Percival  Pott  (1781)  are  much 
more  exact.  He  stuck  a  needle  through  the  sclerotic;  with  this  he  im- 
paled the  lens,  and  tried  by  repeatedly  turning  the  instrument  to  destroy, 
as  much  as  possible,  the  capsule  and  the  lens,  so  as  to  prepare  it  for  resorp- 
tion. This  new  method  found  many  followers,  especially  among  Pott's 
countrymen.  Hey,  Saunders,  Adams;  and  by  the  latter  was  improved.  The 
Englishmen,  and  not  without  right,  claim  the  honor  of  inventing  this 
method  of  breaking  up  the  lens  through  the  sclerotic.  However,  if  we 
acknowledge  Pott  as  the  founder  of  this  method,  this  is  not  exactly  cor- 
rect, since  when  we  use  the  word  ^'discission"  today  it  also  carries  with  it 
the  thought  of  keratonyxis;  and,  furthermore,  the  expression,  "discissio 
cataradae,  as  can  be  proven,  was  not  used  until  1824.  Hence,  Pott's  opera- 
tion should  be  designated  as  a  breaking  into  pieces,  {''dislaceratio"),  if  we 
do  not  wish  to  take  up  Himly's  suggestion,  which  will  be  referred  to  again.'' 
"Discission  through  the  cornea  {keratotiy.rtfi  cum  disciftsio  cataractae)  is  even 
of  later  date.  This  likewise  has  its  previous  history.  Wenzel  and  Gleize,  in 
their  writings,  state  that  cataracts  after  the  opening  of  their  capsules  have 
been  gradually  resorbed  in  the  anterior  chamber.    Conradi  and  Beer  attempted 


282 

to  cut  the  anterior  capsule  in  a  methodical  manner.  Their  results,  possibly 
due  to  a  laclc  of  method,  were  not  favorable,  and  they  gave  it  up  again.  In 
1800  Buchhorn  published  the  results  of  experiments  made  by  him,  at  the  insti- 
gation of  his  teacher  Reil,  in  which  he  incised  the  anterior  capsule  of  the  lens 
through  to  cornea  (here  originates  the  word  keratonyxis),  in  the  eyes  of  corpses 
and  animals. 

"Langenbeck,  to  whom  he  sent  a  copy  of  his  dissertation,  then  carried  out 
in  operative  practice,  keratonyxis;  that  is,  incising  through  the  cornea  and  the 
capsule  of  the  lens.  Of  all  the  innumerable  writings  with  which  literature  is 
replete  concerning  this  operation  of  keratonyxis.  it  is  only  necessary  to  men- 
tion here  the  dissertation  of  Hulverding  (Wien,  1824),  because  it  was  through 
him  that  the  word  discissio  (it  is  to  be  written  with  two  ss,  not  one.  It  is  de- 
rived from  discindere,  to  split  up,  to  tear  to  pieces),  was  introduced  into  opthal- 
mology.  However,  we  must  not  lose  sight  of  the  fact,  that  as  far  as  Buchhorn 
and  Langenbeck  were  concerned,  they  did  not  in  the  beginning  look  upo&  it  as  a 
new  method  by  which  without  injury  to  the  posterior  capsule,  the  contents  of  the 
capsule,  was  by  means  of  the  aqueous  to  be  resorbed.  but  they  rather  looked  upon 
it  as  a  new  method  in  which,by  means  of  a  corneal  puncture,the  lens  could  either 
be  depressed,  as  was  done  by  Celsius,  or  be  broken  up,  as  was  done  by  Pott. 
Only  gradually,  without  any  particular  person  being  deserving  of  the  honor,  out 
of  this  suggestion  of  Buchhorn,  tlie  discissio  cataractae  s.  capsulae  lentis,  as  we 
know  it  today,  was  evolved.  It  would  not  be  out  of  place  to  accept  Himly's 
suggestion,  and  use  synonymously  with  our  discissio,  punctio  capstilaris,  the 
word  dislaceratio  with  discissio.  One  can  hardly  refrain  from  expressing  the 
greatest  astonishment  that  it  should  have  taken  so  long  to  come  upon  a  method 
which  we  so  frequently  see  clinically  exemplified  in  cases  of  injury,  following 
which  the  lens  is  absorbed. 

One  must  not  fail  to  supplement  the  above  by  the  suction  niefhod,  a 
method  which  Sichel  shows  us,  was  known  to  the  ancients,  and  states  that 
the  Arabs  learned  it  from  the  Persians.  In  our  time,  it  has  been  re-invented 
by  Laugier,  and,  as  literature  attests,  is  practiced  today.  "  By  means  of  a 
trocar,  which  is  pushed  through  the  cornea  into  the  lens,  the  soft  and  fluid 
portions  of  the  lens  may  be  aspirated  through  a  canula,  and  thus  an  entire 
cataract  may  be  removed  from  the  eye,  just  as  where  an  extraction  is  made. 
Taking  into  consideration  the  manner  of  procedure,  and  the  size  of  the 
wound,  this  method  approaches  that  of  discission.  Since  today  we  are  in 
a  position  in  most  cases  to  diagnosticate  a  soft  cataract,  it  is  to  be  supposed 
that  this  iiiotlidd  will  remain  in  use  for  special  cases. 


283 
CHAPTER   III. 

THE  PKOC'EDUHES  AND  CILVNGES  JN  THE  EYE  DURING  AND 
SUBSEQUENT  TO  CATARACT  OPERATIONS. 

In  order  that  we  may  understand,  and  become  fully  acquainted  with 
the  injuries  which  an  eye  necessarily  receives  while  undergoing  a  cataract 
operation,  and  that  we  may  become  familiar  with  those  setinelae  which  do 
follow,  and  others  which,  under  certain  conditions,  are  sure  to  be  added,  we 
may  follow  a  variety  of  plans.  Where  one  possesses  an  accurate  knowledge 
of  the  anatomy  of  the  eye,  and  of  the  operative  procedures,'  though  he  may 
have  no  clinical  experience,  he  certainly  can  attain  a  very  clear  theoretical 
conception  of  all  these  procedures.  Thus,  in  1733,  Frances  Petit,  in  his 
published  "Reflexions,"  exerted  an  influence  on  practical  opthalmology,  in 
that  among  other  things  he  showed  that  tlie  iris  is  not  vaulted,  as  it  appears 
to  be  when  seen  through  the  cornea. 

The  physician  finds  a  second  method  of  observation  in  watching  the. 
healing  process  of  the  operated  eye.     For  this,  we  are  indebted  to  Von 
Jacobson,  who  did  this  in  a  methodical  manner,  beginning  with  the  first 
hour  after  the  operation.     His  writings  concerning  this  matter  are  truly 
classical. 

Finally,  here,  just  as  in  General  Medicine,  the  study  of  the  pathological 
anatomy— that  is,  the  anatomical  examination  of  eyes  which  had  been 
operated  on  for  cataract— teaches  us  the  reasons  for  our  clinical  observa- 
tions, and  assists  us  in  drawing  conclusions,  by  means  of  which  the  ill 
results  may  in  the  future  be  avoided  or  controlled.  Both  branches  of  path- 
ological anatomy  are  here  of  equal  importance;  the  experimental,  as  well 
as  the  descriptive  pathological  anatomy. 

Along  these  three  lines,  all  these  processes  which  occur  in  eyes  which 
have  been  operated  for  cataract  shall  be  studied  and  enumerated,  going 
over,  first,  briefly,  the  methods  of  healing  and  the  sequelae,  as  observed  in 
reclination  and  discission.  But,  since  reclination  is  but  little  practiced  at 
the  present  day;  hence  our  personal  observations  are  but  limited.  Many 
of  the  evil  sequelae  of  discission  fall  in  the  same  category  with  those  of 
reclination;  in  part  they  lead  to  the  same  final  results,  as  have  been  ob- 
served when  a  large  portion  of  lens  substance  remains  after  a  cataract  ex- 
traction. In  fact,  as  we  shall  see  further  along,  there  are  certain  clinical 
pictures  which  develop  in  almost  exactly  the  same  manner,  no  matter  which 
method  is  practiced.  Owing  to  their  great  importance,  the  attempt  will  be 
made  to  give  an  exhaustive  account  of  our  present  position  and  knowledge 
of  the  changes  which  take  place  subsequent  to  a  cataract  operation. 

First  of  all,  the  reader  is  reminded  of  the  far-reaching  and  beneficial 


284 

effects  which  the  study  of  bacteriology  has  had,  not  only  on  general  sur- 
gery, but  also  on  this  particular  branch  of  the  same.  In  no  other  depart- 
ment is  such  painstaking  care  requisite  to  prevent  infection.  Not  only 
must  the  eye  and  its  adnexa  be  absolutely  free  of  infection  before  an  opera- 
tion is  undertaken,  but  the  same  care  and  attention  must  be  given  to  the 
instruments,  the  bandage  and  the  eye  water  used  during  and  after  the 
operation  and  during  ihe  processes  of  healing.  Truly,  to  prevent  infection, 
here,  if  anytvhere,  the  price  of  success  is  eternal  vigilance.  This  one  factor, 
"infection,"  is  responsible  for  more  poor  results  than  all  the  others  com- 
bined, and  its  occurrence  will  explain  many  of  the  pathological  conditions 
to  be  enumerated.  He  who  ivill  read  between  the  lines,  will,  in  the  follow- 
ing pages,  note  the  effect  of  infection. 

A. 
EECLINATION. 

The  operative  procedures,  by  means  of  which  a  displacement  of  the 
lens  is  purposely  and  skillfully  brought  about,  differ  from  each  other,  as 
we  have  seen,  in  more  ways  than  one,  depending  on  whether  the  needle- 
like instrument  which  we  employ  is  pushed  through  the  cornea,  or  the 
sclera,  and  also  upon  the  position  in  the  eye,  into  which  the  cataract  is  to  be 
brought.  The  thrust  wound  through  the  cornea  which  is  made  in  kera- 
tonyxis  is,  as  a  rule,  followed  by  but  slight  consequences;  but,  nevertheless, 
we  meet  with  cases  in  which  the  reaction  has  been  very  great,  and  the 
operation  followed  by  iritis  and  cyclitis.  If  the  needle  is  poorly  con- 
structed, so  that  during  the  operation  the  aqueous  is  evacuated,  there  will 
be  added  to  the  injury  of  the  eye,  which  must  necessarily  tak6  place  during 
the  act  of  tilting  the  lens  over,  an  entire  transposition,  equal  to  the  depth 
of  the  anterior  chamber,  of  the  contents  of  the  eyeball,  and  this  transposi- 
tion, during  discission,  not  infrequently  complicates  the  surgical  procedure 
in  a  most  detrimental  manner;  however,  during  extraction,  this  can  never 
be  avoided. 

In  making  a  sclerotonyxis,  the  needle  wounds  the  conjunctiva,  the 
sheath  of  the  ninsele,  rccfuf<,  e.vternvs.  or  the  musck'  itself;  the 
sclerotic,  tlie  choroid,  and  the  ciliary  portion  of  the  retina.  It  then  reaches 
the  vitreous,  and  then  the  danger  arises  of  puncturing  one  of  the  ciliary 
processes,  and  finally  it  passes  through  the  zonula  zinii.  Thereupon,  it 
either  enters  the  lens  behind  the  aequator  and  leaves  it  again  in  the 
periphery  of  the  anterior  capsule,  and  finally  comes  in  contact  with  the  iris; 
or,  without  touching  it,  makes  its  appearance  in  the  pupil,  with  its  surface 
in  contact  with  the  anterior  capsule,  (Willburg,  Scarpa):  or  it  grasps  the 


285 
lens  at  its  upper  edge,  in  order  to  depres>  it.  in  whicli  ;in  iiijui'v  to  the  lens 
before  the  act,  is  not  always  necessary.  (CcLsiiis).  Hence  the  injury,  on 
making  a  sclerotonyxis;  the  simi)lc'  piiiuture  with  the  needle,  is  a  more 
serious  procedure,  and  differs  further  from  the  keratonyxis,  in  that  the 
channel  of  the  wound  through  vascular  tissues  and  the  possibility  of  punc- 
turing a  choroidal  vessel  (Celsius),  or  a  ciliary  ])rocess  exists,  and  of  thus 
causing  an  internal  hemorrhage.  Nevertheless,  experience  has  taught,  thai 
even  this  method  of  ])uncture  is  frequently  tolerated  without  evil  conse- 
quences. Where,  after  reclination  in  any  particular  case,  infiammatorv 
symptoms  develop^  we  are  not  able  to  exclude  the  fact,  that  the  peculiar 
nature  of  the  channel  of  the  puncture  is  in  all  probability  responsible  for 
the  trouble.  (Infection.)  Arlt  (operations  lehre,  p.  255)  considers  it  as  the 
usual  oeciirrence,  where  we  operate  after  Scarpa,  that  the  needle  passes 
througli  rhe  -?dge  of  the  lens  and  the  anterior  capsule,  and  on  raising  the 
handle  of  the  instrument,  the  anterior  capsule  bursts;  and  if  the  cataract  is 
hard  enough,  it  will  be  forced  into  the  vitreous  through  the  previously 
torn  posterior  capsule.  Hence,  in  making  a  dislocation  of  the  lens,  we 
either  cause  a  rupture  of  the  posterior  and  anterior  capsule;  or,  at  times,  a 
partial,  at  times,  a  complete  detachment  of  the  lens  in  its  capsule  from  the 
zonula  zinii;  with  or  without  at  the  same  time  injuring  the  capsule.  Hence 
the  hyaloidea  in  the  hollow  groove  of  the  vitreous  must  be  torn,  and  the 
tissue  of  the  vitreous  forced  asunder,  in  order  to  permit  of  the  lens  occu- 
pying a  certain  amount  of  space.  In  which  part  of  the  vitreous  the  lens 
will  finally  come  to  rest,  and  the  manner  in  which  its  surface  will  lie,  de- 
pends on  the  method  pursued. 

It  stands  to  reason,  that  it  is  impossible  for  the  eajtsule  to  be  torn,  or 
for  the  lens  to  become  detached  from  the  zonula  zinii,  or  for  the  hyaloidea 
to  be  ruptured  without  at  the  time  exerting  a  certain  amount  of  traction 
on  the  corpus  ciliare  and  the  parse  ciliaris  retinae.  The  force  and  influ- 
ence which  the  traction  will  exert  on  the  future  welfare  of  the  case  depends 
partially  on  the  certainty  and  the  delicacy  with  which  the  operation  is  made, 
and  partly  also  on  the  intimacy  which  exists  between  the  lens  and  its  sus- 
pensory ligament.  As  we  have  already  seen,  this  connection  becomes  looser 
as  age  advances;  more  particularly  so,  where  a  shrinking  capsular  cataract 
has  developed.  The  performance  of  the  operation  and  the  nature  of  the 
cataract,  influence  the  extent  of  the  injury  whicli  the  vitreous  must  re- 
ceive. There  will  be  but  slight  resistance  to  the  dislocation  of  a  hard, 
!:hrunken  lens,  whereas  the  traction  on  the  ciliary  body  will  certainly  be 
greater,  where  a  cataract  is  but  partially  cloudy,  or  where  the  cataract  is 
•oft.  When  the  entire  lens  system  has  been  reclinated,  there  is  less  danger 
for  it  to  mount  up  again,  whereas  in  cataracts  which  have  a  less  tough  con- 


286 

sisteiiee,  the  capsule  is  torn  in  the  greatest  variety  of  ways,  and  a  portion 
of  its  shreds  will  remain  in  connection  with  the  reclinated  lens.  On  this 
account,  in  the  latter  cases,  the  reclinated  cataract  more  frequently  mounts 
up  again,  thus  necessitating  a  repetition  of  the  steps  of  reclination,  and 
thereby  increasing  the  injury  to  and  destruction  of  the  vitreous.  The 
result  of  the  operation  depends  greatly  on  the  consistence  of  the  vitreous. 
If  it  is  normal,  it  will  naturally  offer  greater  resistance  to  the  sinking  of 
the  cataract;  but,  at  the  same  time,  if  the  foreign  body  has  once  been  taken 
up.  it  will  be  held  all  the  firmer,  since  both  its  point  of  entrance  and 
the  channel  which  it  made  for  itself  will  close  up  and  heal  all  the  sooner. 
A  fluid  ^dtreous  will  offer  but  little  resistance  to  the  cataract,  as  we  see  it 
in  cases  of  spontaneous  luxation  of  the  lens,  but  on  the  other  hand  it  will 
offer  no  resistance  to  the  independent  movements  which  the  foreign  body 
may  make.  As  we  shall  see  further  on,  fluidity  of  the  vitreous  may  be  a 
result  of  reclination,  hence  this  will  explain  how  it  happens,  that  cataracts 
which  have  not  been  fully  resorbed  may  after  many  years  spontaneously 
mount  up  again. 

Further,  it  depends  on  the  nature  of  the  cataract,  especially  its  con- 
sistency, whether  it  will  be  necessary  to  go  through  the  movements  of 
reclination  a  number  of  times,  and  it  depends  largely  on  the  factor  whether 
or  not  the  lens  will  be  depressed  in  the  vitreous  as  a  single  mass,  or  divided 
into  a  number  of  pieces.  This  certainly  must  exert  an  influence  on  the 
pathological  processes  which  take  place  in  the  eye  after  an  operation.  From 
that  which  has  been  said,  it  must  become  evident,  that  in  this  method  of 
operating  more  than  in  any  other  which  we  will  consider,  great  differences 
will  be  found  in  the  results,  even  of  operations  which  have  been  most  suc- 
cessfully executed.  (Stellwag,  1.  c,  p.  771).  In  considering  the  processes 
of  healing,  it  does  not  suffice  to  eliminate  the  operative  procedure;  but, 
owing  to  the  reaction  of  the  lens  in  the  eye,  pathological  conditions  are 
produced  which  under  certain  conditions  may  require  weeks,  months  and 
even  years  to  subside.  The  dislocated  lens  is  to  be  looked  upon  as  a  foreign 
body  which  possesses  the  peculiarity  that  it  may  be  dissolved  and  absorbed, 
and  this  pathological  condition  may  only  be  looked  upon  as  ended  when  the 
above  conditions  have  been  fulfilled.  But  since  in  these  cases  such  a  complete 
resorption  never  takes  place,  hence  Just  such  eyes  never  become  free  of  this 
diseased  condition. 

If,  by  means  of  these  lever-like  movements,  the  lens  is  successfully  re- 
moved from  the  pupillary  area,  so  that  it  does  not  mount  up  again,  and  no 
signs  of  reaction  follow,  one  might  almost  say  that  the  immediate  result 
of  the  operative  procedure  is  wonderful.  Truly,  one  must  have  been  pres- 
ent and  witnessed  snch  a  procedure — something  wliieh  is  hardly  vouchsafed 


2,S7 
the  yoiino-er  generation  of  oculists — to  fonii  any  idea  of  the  impression 
which  the  sudrlenl_y-attained  bhick  pupil  makes,  ami  to  witness  tlic  radiant 
joy  of  tlie  patient  who  has  had  his  sight  suddenly  restored  to  liim.  And.  in 
fact,  such  cases  were  not   of  infretpient  occurrence. 

A  reclination  which  is  made  without  a  mishap  is  often  followed  by 
no  reaction  whatever.  The  eye  remain-  pci-rccily  ])alc.  the  lens  does  not 
mount  up  again,  and  in  the  course  of  a  week  the  patient  is  permitted  to 
use  liis  eye.  In  other  cases  the  conjunctiva  becomes  reddened,  the  eye  irri- 
table to  light  and  tears  a  few  days;  this,  however,  soon  subsides,  and  the 
use  of  the  eye  is  delayed  a  few  days. 

If  ciliary  injection  sets  in,  one  must  decide  if  this  is  partial,  or  if  the 
entire  cornea  is  encircled.  Even  in  tlie  lirst  condition  t!ie  conjunctiva  be- 
,gins  to  swell  up;  there  is  considerable  secretion,  the  iris  becomes  discolored, 
vascularization  becom.es  distinct  and  leads  to  exudation.  After  a  time  this 
abates,  leaving  a  few  synechia.  iVfter  all  these  inflammatory  symptoms 
cease,  we  find  the  pupil  drawn  in  the  direction  in  which  the  lens  was  re- 
clinated,  and  a  secondary  cataract  of  greater  or  less  thickness  can  be  seen. 
The  usefulness  of  the  eye  will  depend  on  the  thickness  of  this  latter  cata- 
ract. 

If  the  ciliary  injection  is  not  restricted  to  th?  neighborhood  of  the 
point  of  puncture,  the  conjunctiva  will  become  chemotic,  iritis  develops, 
and  one  can  discern  through  the  pupil  that  the  capsule  is  involved  in  the 
inflammatory  process.  This  disease  lasts  longer,  and  not  infrequently  leads 
to  total  occlusion  of  the  pupil.  How  much  of  a  result  can  be  obtained  by 
a  subsequent  operation  in  such  a  case,  to  increase  vision,  I  can  not  state 
from  personal  observation,  nor  have  I  been  able  to  find  any  reports  in  liter- 
ature. It  appears  that  the  so-called  subsequent  operations  have  but  lately 
been  adopted  (1876).  If  the  pupil  is  not  entirely  occluded,  a  greater  or 
less  amount  of  vision  may  still  be  oljtained.  If  these  symptoms  increase, 
hypopyon  develops,  and  then  the  pupil  will  give  a  yellowish  reflex.  These 
cases  may  terminate  in  one  of  two  ways.  During  the  gradual  resorption 
of  the  hypopyon  and  total  occlusion  of  the  pupil,  phthisis  hulbi  gradually 
develops;  this  process  takes  months,  and  is  accompanied  from  time  to  time 
by  pain;  sensibility  to  light  is  totally  abohshed,  or  may  for  a  time  still  be 
present.  Or  the  pus  is  not  resorbed.  but  evacuates  itself  at  some  point, 
most  frequently  in  the  neighborhood  of  tlie  point  of  puncture,  finding  its 
way  outward  through  the  sclerotic.  But  seldom  has  .ulceration  of  the 
cornea  been  observed.    (Daviel).     (This  is  the  picture  of  an  infection). 

The  above-named  forms  of  disease  may  be  complicated  by  portions 
of  the  lens  remaining  in  the  pupil,  floating  about  in  the  vitreous,  or  getting 
into  the  anterior  chaml)er.     Before  a  useful  amount  of  vision  can  be  at- 


288 

tained  these  must  first  be  resorbed  and  eliminated  from  tlu'ii-  respective 

positions. 

These  processes  may  not  develop  at  once  in  the  manner  described,  but 
may  develop  suddenly  in  an  entirely  imexpected  manner  after  the  lapse  of 
monihs  or  years  in  cases  which  had  apparently  terminated  most  success- 
fully. There  are  also  cases  in  which,  without  any  premonitory  symptoms, 
or  without  any  outward  signs,  a  serous  choroiditis  develops,  leading  to 
glaucoma  and  amaurosis.  Finally,  cases  are  reported  from  the  remotest 
antiquity,  in  which  lenses  which  had  been  reclinated  for  thirty  years,  sud- 
denly mounted  up  again  in  a  vitreous  which  had  become  fluid,  and  began 
moA-ing  about  freely,  and  for  a  time  return  to  occupy  their  former  position 
in  the  pupil,  or  by  accident  getting  into  the  anterior  chamber,  thus  causing 
secondary  glaucoma. 

"The  anatomical  examination  of  eyes  on  which  the  operation  of  reclination 
has  been  practiced  has  explained  to  us  the  reasons  for  the  various  clinical  pic- 
tures that  have  been  described.     The  literature  which  reports  the  examination 
of  eyes  on  which  reclination  had  been  practiced  is  considerable.     The  epoch- 
making  examination  of  Brisseau  was  made  on  an  eye,  on  which  this  operation 
had  been  made  after  death.    Maitre  .Jean,  Heister,  Morgagni  and  others  corrob- 
orated by  their  post-mortem  examinations  on  non-operated  corpses  the  ana- 
tomical nature  of  grey  cataract;  these,  however,  were  soon  followed  by  a  num- 
ber of  others,  Deider,  Henkel,  Boerhaven,  Hein,  Pott,  Scarpa.  Acrel.  Earl  and 
Hesselbach,  and  these  again  by  Soemmering  and  Textor,  who  were  almost  ex- 
clusively interested  in  the  fate  of  the  torn  capsule  after  reclination,  and  also 
of    the  reclinated  lens;    and  only  in  a    passing  way  paid    attention  to    other 
changes  which  they  found  in  the  eyes.     The  first  accurate  examination  of  an 
eye  on  which  reclination  had  been  practiced,  and  which  was  obtained  for  patho- 
logical examination  during  the  period  of  reaction,   was  made  by  Rienker,  in 
the  year  1834.    This  was  followed  by  examinations  made  by  Von  Graefe,  Iwan- 
off  and  Pagenstecher,  so  that  today  we  possess  quite  accurate  anatomical  in- 
formation regarding  the  more  important  processes,  even  those  which  occur  in 
the  most  serious  cases  after  reclination.     A  short  time  after  scleronyxis  it  is 
often  impossible  to  find  the  cicatrix  of  the  puncture.    Nevertheless,  in  one  case 
Soemmering  was  able  to  recognize  the  point  of  puncture  thirteen  months  after 
the  operation;  in  another,  eight  and  a  half  years  later.     This  was  recognized 
as  a  dark  spot,  one  and  a  half  lines  from  the  cornea,  and  appeared  somewhat 
more  transparent  than  the  rest  of  the  sclera.    Within,  it  was  hardly  a  line  from 
the  edge  of  the  retina,  but  on  the  folded  edge  of  the  cornea  it  could  not  be 
i-fognized.     Puncture  wounds  of  tlie  cornea  will  be  presently  considered." 

'I'lic  (  li.uigcs  wliich  ihc  capsule  undergoes  after  reclination.  v;iry  greatly.  If 
ihc  lens,  fogctlici-  with  its  capsule,  has  been  reclinated.  naturally  no  trace  of 
Ihc  lattci-  will  be  foniid  in  the  ])iii(ill:iry  area.    Tlie  t'uttire  cdnditioii  of  the  eye 


2S9 
then  (Icix'uds  on  the  I'jict,  wlictlici-  or  not  any  considerable  inflammatory  symp- 
toms follow  tlio  operation.  In  Sonimerin>i's  tiftli  ()i)eration  he  fonnd  tlie  cap- 
sule free  from  its  litiainent  and  its  entire  (•ir<-uniference  except  at  tiie  lower 
edge,  where  it  was  still  attached  to  the  zonula.  Sommerint;  leaves  tlie  (piestiou 
an  open  one,  as  to  whether  the  capsule  was  separated  and  depressed  without 
tearing,  or  if  there  was  originally  a  small  tear  which  had  closi'd  again. 

Opinions  differ  greatly  regarding  the  frequency  with  which  the  lens,  to- 
gether with  its  capsule,  is  reclinated.  Stellwag  (1.  c,  p.  614)  declares  as  the 
result  of  his  investigations  that  cases  of  primary  cataract  dislocation  in  the 
capsule  are  an  exceedingly  rare  occurrence.  Hence,  the  statement  of  Beer 
(1.  c,  II.  p.  364).  who  in  former  years  found  reclinated  lenses  in  their  capsules, 
as  also  did  Richter  (Chir.  Hiblioth.,  II,  322)  and  Szokalski  (Prager  Viertel  Yah- 
resschrift).  are  all  the  more  important,  since  both  after  the  lapse  of  many  years 
extracted  cataracts  which  had  mounted  up  again,  and  were  enabled  to  deter- 
mine that  they  were  enclosed  in  their  capsules.  Stellway  states  that  it  is  pos- 
sible to  find  the  "dry  pod  cataracts." 

If  the  capsule  in  its  entirety,  or  even  a  portion  of  it.  remains  in  direct  con 
tinuity  with  the  zonula,  it  is  impossible  to  perform  reclination.  unless  at  least 
the  posterior  capsule  is  torn.  Five  years  after  reclination  Von  Grate  found 
in  an  eye  which  he  examined  the  anterior  capsule  intact;  whereas,  in  the  pos- 
terior there  was  a  circular  opening  2.5  inches  in  diameter.  Hence,  the  point 
of  the  needle  used  did  not  touch  the  anterior  capsule,  but  remained  imbedded 
in  the  lens  substance.  Stellwag  (1.  c,  p.  608)  stated  that  such  a  thing  is  pos- 
sible, and  Ritter  (91").  p.  9)  proved  it  experimentally.  The  opening  in  the  pos- 
terior capsule  is  not  always  regular.  Stellwag  found  in  post-mortems  made  on 
cholera  patients,  that  the  capsule  was  torn  in  many  directions.  Sometimes 
the  central  portion  was  missing.  But  even  in  these  cases  the  peripheral  por- 
tions" adhere  to  the  anterior  capsule.  If  death  had  followed  shortly  after  theit 
reclination.  they  were  to  be  recognized  as  floating  slireds.  But  if  tlie  patient 
lived  many  years  after  operation  these  shreds  were  always  found  drawn  back, 
and  forming  either  a  part  of  the  crystalline  pearl  (Wulst).  or  as  the  posterior 
portion  of  a  tattered  secondary  cataract,  resembling  in  form  a  cataraeia  sili- 
qtiata;  or  they  were  even  found  together  with  the  anterior  capsule  somewhere 
in  the  eye  rolled  up  like  a  ball. 

Tlie  anterior  capsule  either  dischised  a  simple  hole,  or  a  piece  had  Iteen  torn 
out.  These  shreds  whicli  had  been  torn  loose  resembling  a  clotli  wliich  liad 
been  rolled  up.  were  found  folded  together  in  tlie  vitreous:  tliey  were,  liowever. 
adherent  to  the  nucleus  of  the  lens,  and  were  fiirtlKT.  still  in  coiiueciion  with 
the  uninjured  portion  of  the  zonula,  and  in  this  manner  with  the  corresponding 
ciliary  processes.  In  other  cases  the  anterior  capsule  was  partially  loosened 
from  the  zonula,  and  floated  in  the  aqueous  humor  of  the  posterior  chamber, 
either  alone  or  in  connection  with  the  remains  of  the  posterior  capsule.     Stell- 


290 

wag  described  a  case  in  Avliich  recliuation  nart  been  performed  according  to 
tlie  rules  laid  do%vn.  and  the  anterior  capsule  was  found  adherent  to  the  zonula 
only  below,  and  was  floating  in  the  vitreous  as  a  conglomerated  folded  mass. 

In  every  case  in  which  it  was  shown  that  the  anterior  capsule  had  simply 
l)een  torn,  but  that  its  connection  with  the  zonula  had  not  been  disturbed,  a  so- 
called  crystalline  pearl  or  wulst  had  formed.  This  was  first  accurately  de- 
scribed and  defined  by  Soemmering,  and  dependent  on  conditions  found  in  eyes 
on  whicli  recliuation  had  been  practiced.  The  formation  and  the  anatomy  of 
the  co-called  crystalline  pearl  has  already  been  described  under  secondary  cat- 
aract. 

After  the  lens  has  been  forced  out  of  its  capsule  into  the  vitreous,  the  latter 
must  take  the  place  of  the  former.  Hence,  th  vitrous  will  cause  the  capsule 
to  bulge  out  anteriorly.  But  along  with  the  gradual  shrinkage  and  resorption 
of  the  reclinated  lens,  an  increased  secretion  of  aqueous  takes  place,  and  to- 
gether with  the  formation  of  the  secondary  cataract,  the  two  halves  of  the 
capsule  approach  each  other  so  as  to  lie  almost  in  an  even  plane.  This  is 
found  in  nearly  all  post-mortem  examinations.  Earl  alone  states  that  after  a 
lapse  of  five  months  he  still  found  the  space  formerly  occupied  by  the  cataract 
filled  with  transparent  fluid  vitreous.  Whereas,  Soemmering  states  that  at  the 
end  of  thirteen  months  he  found  a  perfectly  even  partition  wall,  made  up  of 
the  remains  of  a  torn  lens  capsule,  which  separated  the  aqueous  from  the 
vitreous. 

According  to  Soemmering  and  Textor  d.  c.  p.  32)  the  opening  in  the  pos- 
terior capsule  is  at  times  filled  out  by  a  very  delicate,  transparent  membrane, 
which  then  forms  the  partition  wall  between  aqueous  and  vitreous.  This  can 
be  nothing  more  than  the  hyaloidea.  concerning  the  wounds  of  which  Stellwag 
has  observed  that  they  can  heal  without  leaving  a  cicatrix.  It  is  to  be  re- 
gretted that  just  in  this  fifth  observation  of  Soemmering  he  makes  no  men- 
tion of  the  relation  which  he  found  existing  between  aqueous  and  vitreous. 
The  few  statements  which  report  that  after  the  close  of  the  process,  the  vitreous 
is  found  bulging  anteriorly,  are  of  earlier  date.  Even  in  eyes  which  had  very 
good  vision,  an  abnormal  adhesion  was  found  between  the  periphery  of  the 
posterior  capsule  and  the  zonula,  without  the  presence  of  any  synechia.  Such 
thickenings  of  the  zonula  coming  on  after  a  cyclitis  are  not  of  such  rare  occur- 
rence (v.  Graeffe). 

Nearly  all  investigators  seem  to  have  interested  tliemst'lv<'s  mostly  with 
the  fate  of  the  reclinated  lens.  The  position  which  a  reclinated  lens  will  occupy 
must  necessarily  depend  on  the  method  which  is  practiced,,  if  the  operation  has 
been  done  in  a  perfect  manner,  and  further  depends  on  whether  the  lens  does 
or  does  not  completely  or  partially  mount  up  again.  Examination  has  shown 
that  the  reclinated  lens  comes  to  lie  directly  over  the  insertion  of  the  R.  inferior 
(Soemmering.  1.  <■..  ]>.  HO),  at  times  downward  and  outward  in  the  vitreous 
(Soemmering.  Phitc  I.  Fig.  1  and  2.  4.  IMate  II.  Fig.  5.  Textor.  Fig.  'J.  3.  4). 
In  cases  of  incoinph'tc  rccliiuition.  and  following  partial  resorption,  tlie  nucleus 


I 


291 

of  the  lens  may  agniu  bet-oiiio  so  displaced  as  to  get  back  into  the  capsule,  sink 
to  the  bottom,  and  simulate  a  Morgagniani's  cataract  (Textor,  Fig.  1).  The 
opportunity  has  been  but  seldom  oflfered  to  accurately  determine,  at  an  early 
date,  the  position  of  the  surfaces  of  the  lens.  Hence,  it  may  be  a  matter  of 
great  interest  to  state  that  I  (Becker)  have  been  given  n  specimen  by  Dr.  Manz 
(scleronyxls).  in  which  the  lens  lies  somewhat  below  and  inward,  almost  touch- 
ing the  lower  edge  of  the  torn  capsule,  and  with  its  anterior  surface  turned 
upward.  In  Soemmering's  fifth  case  the  lens  must  have  occupied  a  somewhat 
similar  position,  and  four  and  five  years  after  a  reelination  v.  Graeflfe  could 
determine  the  anterior  (less  convex)  surface  of  the  lens  turned  backward  and 
somewhat  upward,  the  posterior  surface  somewhat  forward  and  downward. 

The  illustrations  of  Soemmering  and  Textor  give  us  a  very  good  idea  of 
the  position  in  which  the  lens  finally  becomes  fixed.  It  is  also  very  noticeable 
that  in  Soemmering's  illustrations  we  find  the  lens  lying  further  back  than  in 
Textor's  illustrations.  This  is  probably  due  to  the  fact  that  Soemmering  recli- 
uated  through  the  sclera,  whereas  Textor  did  so  through  the  cornea.  One  can. 
however,  only  then  form  a  correct  estimate  of  the  position  of  the  lens  lies.  If  we 
bear  in  mind  the  position  of  the  center  of  the  lens,  for  since  the  lens  shrinks 
in  the  vitreous;  hence,  in  order  to  judge  how  far  the  lens  is  removed  from  the 
I'Qterior  or  posterior  portion  of  the  eye,  one  must  not  forget  that  this  depends 
on  the  degree  of  shrinkage.  In  Textor's  cases  the  center  of  the  lens  lies  on 
the  folded  portion  of  the  corpus  ciliare,  whereas,  in  Soemmerlng's  they  lie  on 
the  flat  portion,  so  that  before  resorption  his  lenses  must  have  been  partially 
en  the  retina. 

All  reports  agree  in  showing  that  the  post  mortem  examinations  showed 
tbo  volume  of  the  reclinated  lenses  to  be  diminished.  It  is  only  in  the  fifth 
.-(•pert  of  Soemmering  that  he  emphatically  states  that  though  years  had  elapsed 
since  reelination.  the  darkened  and  hardened  lens  in  its  capsule  was  not  re- 
duced in  volume.  Likewise  in  Manz's  case,  no  reduction  in  volume  could  be 
found.  (I  regret  that  I  can  not  give  the  exact  date  of  the  operation.)  In  all 
other  cases  I  find  it  mentioned  how  great  the  reduction  in  volume  was.  or  if 
the  lens  had  entirely  disappeared  without  leaving  a  trace.  The  number  of  the 
latter  observations,  however,  is  not  very  great.  Such  cases  have  been  described 
by  Deider.  Acrel.  Hoin,  Earl.  Soemmering,  Arlt  and  Iwanoff.  However,  it  must 
be  stated  that  in  the  eyes  operated  by  Soemmering  and  Iwanoff  vision  was  de- 
stroyed as  the  result  of  very  severe  inflammation,  so  that  it  is  very  likely  that 
the  lenses  were  destroyed  by  the  purulent  inflammation.  Hence,  with  the  ex- 
ception of  Arlt's  cases,  all  those  reports  of  cases  in  which  good  vision  existed 
after  reelination  with  total  resorption  of  the  lens  are  of  earlier  date.  However, 
both  Acrel  and  Arlt  make  very  positive  statements.  The  former  says  (1.  c,  p. 
109):  "I  examined  the  eye  on  which  the  patient  had  good  vision  subsequent 
to  the  operation,  and  I  find  that  the  depressed  lens  had  been  totally  dissolved 
and  absorbed."  Arlt  says  (p.  346):  "In  a  specimen  taken  from  an  insane  pa- 
tient, who  had  been  operated  nine  years  previously,  not  a  trace  of  the  nucleus 


292 

of  the  lens  could  be  found,  either  in  the  vitreous  or  on  the  retina."  The  volume 
of  the  remains  of  the  lens  varies  greatly,  from  the  scarcely  perceptible  pieces 
to  pieces  the  size  of  millet  seeds— greyish  white  bodies.  (Soemmering,  Beob.  l.,» 
Beyond  a  doubt  the  result  is  greatly  influenced  by  the  consistence  of  the  cata- 
ract, and  dependent  on  the  fact  whethei*.  during  the  operation,  a  great  deal  of 
cortical  substance  is  stripped  off;  also,  whether  the  capsule  is  also  reclinated. 
Time  does  not  seem  to  be  the  only  factor  requisite  to  bring  about  resorption 
of  a  cataract.  Beer  says  (1.  c  p.  364):  "In  fact,  I  have  never  yet  seen  a  cat- 
aract which,  being  held  but  partially  fast,  could  be  entirely  dissolved  and  re- 
sorbed,  and  before  I  will  believe  that  this  can  occur,  I  must  personally  see  a 
depressed,  solid,  hard  cataract  really  dissolved  and  resorbed,  which  I  am  sorry 
to  state  I  have  never  as  yet  been  able  to  see."  In  a  case  which  Hesselbach 
examined,  a  lens  which  had  been  depressed  for  forty-four  years  was  not  en- 
tirely resorbed.  However,  in  these  cases  of  such  long  standing,  examined  by 
Hesselabch  and  others,  deposits  of  lime  salts  were  found  in  the  remains  of 
the  lenses. 

Ritter  described  the  processes  of  resorption  of  the  lens  in  the  vitreous  as 
similar  to  those  which  take  place  in  the  aqueous.  The  fibres  lose  their  close 
and  compact  arrangement,  so  that  the  reclinated  lens  may  later  on  separate 
into  a  number  of  pieces.  The  fibres  shrink,  and  whereas  the  fibres  break  up 
and  become  tumescent,  and  finally  absorbed,  the  membrane  most  probably 
remains  unchanged.  Opinions  differ  greatly  as  to  what  becomes  of  portions  of 
the  capsule  which  get  into  the  vitreous  during  reclination.  Stellwag  states 
(1.  c,  p.  615)  that  he  frequetnly  was  not  able  to  find  pieces  of  capsule  which 
had  been  torn  away  and  fallen  into  the  vitreous.  Likewise,  he  frequently 
found  edges  of  the  posterior  capsule  which  were  still  connected  with  the  an- 
terior capsule  much  reduced  in  size.  Where  the  edge  of  the  posterior  capsule 
was  wanting,  one  could  never  find  any  remains  of  the  posterior.  The  portions 
of  the  latter  which  were  found  imbedded  in  the  crystalline  peai-1  was  never  as 
large  as  those  shreds  which  were  found  adherent  to  the  edge  of  the  anterior 
capsule,  when  the  eyes  were  examined  shortly  after  the  opej;ation.  From  this 
•we  can  assume  that  not  only  dislocated  pieces  of  the  anterior  aud  posterior  cap- 
sule and  those  which  are  torn  out  may  be  absorbed,  but  also  those  which  are 
still  adherent.  Stellwag  himself  seems  to  acknowledge  that  the  whole  capsule 
or  large  pieces  of  the  same  are  not  only  not  absorbed,  but  offer  great  resistance 
to  the  resorption  of  the  enclosed  lens  substance.  This  general  principle  of 
Stellwag's,  which  is  also  met  with  at  other  plnc(>s,  T  desire  to  contrast  with 
the  fact,  that  at  that  time  the  methods  of  nii(  r()S(<)i)i(al  investigation  were  not 
developed  sufficiently  to  distinguish  Avhother  ur  not  very  fine  and  delicate  shreds 
of  the  capsule  were  still  present  in  tlie  eye.  Evt'u  in  cases  wliere  the  entire 
eye  is  destroyed  by  purulent  inflammation,  the  In/dliiir  IinncJUic  of  thr  rlmroid 
withstand  solution,  as  does  also  the  iiiciuhnind  liniihnis  of  the  niiiKu:  even 
when  nothing  else  remains  of  these  structures.  The  same  is  true  of  iiienibnina 
dcsccmrtl  and  of  tlie  ('(ipsidc  of  the  lens,  in  cases  of  traumatic  cataract.     Dr.  Gold- 


293 
zieher  found,  one  year  after  tlic  coiiiplctioii  of  a  raiaran  ..jici  ation.  a  jtiocc  of 
the  capsule  entirely  undiauyed.  enclotsetl  in  ilic  <iiiijiiii<ii\  a!  .i.alrix.  Though 
I  have  observed  very  considerable  swellinii  of  ilic  caiisiilc  nf  tlic  lens,  and 
though  this  might  be  looked  ui)on  as  a  prodromal  stagt;  of  rfS(»ri)tion.  still  I 
do  not  consider  this  as  proven. 

As  has  already  been  mentioned,  a  comi)lete  liealing  of  tlie  hyaloidea  in  the 
hollow  groove  of  the  vitreous  (fossa  patellaris)  after  reclination.  without  having 
a  cicatrix,  has  been  anatomically  determined.  Even  the  path  which  the  lens 
followed  during  the  act  of  depression  coidd  in  some  cases  no  longer  be  found. 
Every  investigator  has  observed,  that  the  vitreous  becomes  thickened  and  filled 
with  cloudy  threads  and  membranes,  in  the  immediate  neighborhood  of  the 
lens.  Even  S(K*mmering  states  that  the  extent  of  these  pathological  formations 
is  proportionate  to  the  degree  of  inflammation  observed  during  life.  Occasion- 
;illy  he  observed  a  positive  nest  of  new  formed  tissue  in  which  the  lens  was 
imbedded.  Even  in  eyes  in  wiiich  the  lens  was  totally  resorbed,  he  could 
plainly  see  the  groove  in  wliicli  the  lens  liad  been  deposited.  In  this  tissue 
Soemmering  even  found  new  formed  blood  vessels.  The  remark  of  Stellwag 
is  very  interesting,  indeed,  in  wliicli  lie  states  that  he  never  found  the  cata- 
ractous  nuclei's  in  direct  contact  with  the  retina.  He  always  found  a  measur- 
able strjituni  oi  vitreous  substance  between  the  surface  of  the  lens  and  the 
retina.  Since  Stellwag's  statements  only  refer  to  eyes  which  had  been  oper- 
ated successfully,  this  coincides  perfectly  with  the  results  obtained  by  H. 
Pagenstecher.  in  his  experimental  investigations.  According  to  the  latter,  a 
foreign  body  may  be  introduced  through  the  sclerotic  into  the  vitreous,  and 
tolerated  for  a  long  time  without  leading  to  a  hyperplasia  of  cells  and  ineap- 
sulation.  If  this  does  take  place,  it  always  extends  from  the  point  of  puncture 
to  the  place  where  the  foreign  body  rests.  This  hyperplasia  takes  place  more 
certainly  and  more  quickly  when  the  foreign  body  is  in  contact  with  the  retina. 
The  view  held  by  many  oculists,  namely,  that  the  pressure  which  the  lens 
exerts  on  the  coats  of  the  eye,  especially  the  retina,  causes  the  severe  reaction 
after  reclination.  is  by  this  means  fully  explained,  as  are  also  the  observations 
of  Stellwag.  Leber,  in  his  masterly  work  already  so  often  quoted  (Die  Entzun- 
dung.  Leipsig.  1891).  lias  shown  tliat  tlie  inflammatory  reaction  within  the 
eye  is  due  to  the  action  of  micro-organisms  and  the  ptomaines  which  they  pro- 
duce. In  his  experiments  with  sterile  particles  of  metals,  and  with  various 
chemicals,  he  has  sliown  tliat  th(>  former  are  gradually  acted  on  by  the  vitreous 
dissolved  oft',  and  even  in  the  miinitest  quantities  like  chemicals  exert  an  irri- 
tjiting  iiitiuence.  .lud  give  rise  t(t  inflammation  of  ascei)tic  or  chemically  pro- 
duced pus.  'I'his  inflammation  may  be  of  a  very  low  grade  and  chronic  variety, 
and  gradually  lead  to  destruction  of  the  vitreous. 

The  compar.atively  frequent  observation,  namely,  that  in  successful  cases 
of  reclination.  the  reclinated  lens  is  found  still  held  in  connection  with  the 
lower  portion  of  tlie  zonula,  will  exjtlain  why  this  detrimental  pressure  on  the 
retina   and   corpus   ciliare  does   not   so  often   overstep   tlie   limit  of  endurance. 


294 

The  zonula  fibres  act  like  an  elastic  spring,  counteracting  the  pressure  which 
the  lens  would  otherwise  exert.  The  elasticity  of  this  membrane,  and  with 
perfect  right,  has  been  enumerated  as  one  of  the  causes  for  the  mounting  up 
again  of  the  lens.    This,  however,  is  not  the  only  cause. 

Time  and  again  post  mortem  examinations  have  shown  the  vitreous  to  be 
fluid  (Soemmering,  Acrel  and  others).  A  synchisis  before  the  operation  would 
necessarily  defeat  the  results  of  an  operation.  Just  as  a  fluidity  of  the  vitreous 
is  to  be  looked  upon  as  a  cause  of  spontaneous  luxation,  it  must  likewise  favor 
a  reclination  of  tlie  lens:  but  it  will  also  prevent  a  permanent  result.  If  the  fluid- 
ity is  a  result  of  the  iccliiiation.  it  will  depend  on  tlie  kind  of  adhesion  whether 
or  not  the  lens  will  become  freely  movable  in  the  vitreous.  Various  observers 
have  found  the  reduced  lens  floating  freely  in  the  vitreous. 

Stellwag  (1.  c,  p.  618)  describes  a  peculiar  form  of  fluidity  of  the  vitreous, 
■which  seems  only  to  affect  the  anterior  and  middle  portion;  but  with  this  I 
am  neither  familiar  from  personal  observation,  nor  from  the  statements  of 
others.  He  says:  "Very  frequently  he  finds  the  vitreous  reduced  to  such  a 
degree  that,  aside  from  the  portion  which  is  applied  to  the  retina,  there  is  a 
space  anteriorly  which  is  filled  wltli  watery  fluid."  And  he  adds  (with  perfect 
right):  "and  when  the  portion  of  the  vitreous  in  contact  with  the  nucleus  of 
the  cataract  becomes  fluid,  the  position  of  the  latter  in  the  future  will  be  deter- 
mined by  its  speciflc  weight.  On  moving  the  eye  about  we  can  then  see  it 
dancing  about  inside  the  globe,  and  it  may  possibly  get  into  the  anterior 
chamber. 

Such  a  fluidity  of  the  vitreous,  coming  on  long  after  an  operation,  has  for 
a  long  time  been  looked  upon  as  the  cause  of  amaurosis  without  cloudiness  of 
the  transparent  media,  or  without  detachment  of  the  retina.  (Secretion  glau- 
coma of  V.  Graefe).  This  was  first  described  by  Beck  and  later  again  by 
V.  Graefe. 

The  connective  tissue  threads,  which  in  cases  wliieh  take  a  favorable  course 
totally  surround  the  lens  and  hold  it  in  its  position,  can  be  most  easily  de- 
scribed as  the  products  of  a  circumscribed  cyclitis,  and  of  that  particular  va- 
riety which  by  preference  originates  in  the  pars  ciliaris  retinae.  The  amount 
of  new  formed  tissue  permits  us  to  estimate  the  intensity  of  the  cyclitis.  and 
Soemmering  has  described  and  illustrated  stages  of  development  of  this  pro- 
cess. We  possess  the  reports  of  more  eXact  examinations  made  by  Rieneker, 
V.  Graefe  and  Iwanoff,  in  which  vision  had  been  totally  destroyed  as  the  result 
of  cyclitis  and  its  various  complications  subsequent  to  reclination.  Rieneker 
examined  an  eye  on  which  keratonyxis  had  been  practiced  eleven  days  pre- 
viously by  means  of  a  Scarpa's  needle.  Violent  inflammation  followed,  intense 
chemosis,  hypopyon  and  ji  yellow  reflex  from  the  pupil  was  noted.  The  eye 
became  amaui'otic  on  the  fourth  day;  the  light  sense  remained  nihl,  but  the 
inflammatory  symptoms  subsided  a  few  days  before  death.  On  post  mortem 
examination  the  point  of  puncture  could  only  be  found  existing  as  a  fine  cica- 
trix.    At   the  lower  portion  of  the  anterior  chand)er  exudate  was  still  present 


295 
(liyi)Oi».von».  wliich  liimly  .-mIIi. M-fd  to  ih,-  ntnw.i  .-nul  iris.  Tlic  tii.|.cr  half  of 
the  iris  bad  a  gioeiiish  disouloratiou.  and  in  the  neifihborhood  of  the  hypopyon 
were  small  echynioses.  The  moderately  dilated  pupil  was  in  about  two-thirds 
of  its  area  filled  with  exudate.  The  retina  was  loosened  up  and  of  a  grey  color; 
the  choroid  was  of  a  brownish  red  color.  Extravasated  blood  lay  between  the 
retina  and  the  vitreous.  The  vitreous  was  very  consistent,  and  of  a  greenish 
color.  To  the  temporal  side  was  a  mass  of  pus  about  the  size  of  a  beau.  In 
front  of  this,  to  the  outer  and  lower  side  of  the  uvea  lay  the  lens,  on  the  ciliary 
baud,  between  hyaloidea  and  nervea.  Close  to  the  lens  was  an  ecchymosis. 
The  lens  was  swollen,  externally  soft  and  flaky,  internally  hard.  In  the 
neighborhood  of  the  lens  the  sclerotic  seemed  to  be  normal.  This  is  the  only 
case,  which  I  have  been  able  to  find  in  literature,  in  wliich  the  sequelae  follow- 
ing reclination  and  acute  purulent  irido  choroiditis,  has  been  described  in  a 
perfectly  clear  and  comprehensive  manner,  taking  into  consideration  the  time 
when  it  was  written.  (No  doubt  bacteriological  investigation  would  have  dem- 
onstrated the  presence  of  staplylococci  and  streptococci).  It  appears  that  Iwan- 
off  must  have  examined  a  similar  case.  In  the  eye  which  Moren  examined 
(1.  c.  p.  35)  the  globe  had  retained  its  form  and  size,  retina  and  choroid  were 
in  their  normal  position,  the  vitreous,  however,  was  drawn  forward,  so  that 
its  anterior  posterior  chamber  measured  but  8  mm.  Downward  and  outward, 
where  in  Rienelcer's  case  the  lens  lay,  there  was  found  an  abscess  in  the  stage 
of  inspisation.  The  only  remains  of  the  lens  was  a  crystalline  pearl.  This 
was  everywhere  enclosed  in  a  thickened,  new  formed  tissue,  which  posteriorly 
gradually  disappeared  in  the  vitreous,  and  anteriorly  bound  this  crystalline 
pearl  tightly  to  the  iris.  The  pathological  conditions  were  .iust  as  intimate 
with  the  ciliary  body,  which  had  likewise  been  changed  by  inflammatory  prod- 
ucts. Both  retina  and  choiroid  showed  increase  of  tissue  change,  more  an- 
teriorly than  posteriorly.  Anteriorly  the  former  showed  many  spaces  filled  with 
fluid,  and  many  round  cells,  and  the  latter  a  more  intimate  connection  of  the 
various  lamellae  could  be  made  out,  especially  between  the  pigment  epithelium 
and  the  vitreous  lamellae  of  the  choroid.  We  recognize  the  description  as  that 
of  a  typical  case  of  irido-eyelitis.  Von  Graefe  examined  a  blind  eye  four  or 
five  years  after  reclination  had  been  practiced.  During  life  one  could  not  de- 
termine any  other  diseased  condition  than  a  rigidity  of  a  moderate  sized  pupil, 
in  the  center  of  which  one  could  see  a  secondary  cataract.  Post  mortem  exami- 
nation showed  that  the  iris  was  not  adherent  to  the  secondary  cataract.  The 
latter,  however,  was  held  adherent  to  the  zonula  by  means  of  an  exudate,  and 
by  means  of  this  also  with  the  ciliary  processes.  In  the  retina  could  be  seen 
countless  small  and  large  whitish  granules  and  nodule.s.  and  part  of  these  ex- 
tended into  the  choroid.  At  some  places  they  formed  large  i>laques.  On  micro- 
scopical examination  all  of  these  were  found  to  form  a  continuous  sheet  be- 
tween retina  and  choroid,  which  at  the  orrata  serrata  became  continuous  with 
both  membranes  in  their  entirety.  In  the  vitreous  the  direction  which  the  lens 
had  taken  could  be  followed  by  means  of  a  new  formed  connective  tissue  mass, 


296 

which  h'jul  to  ;i  im^inbriinous  jKxket  in  the  vitreous,  and  was  located  dowmvard 
and  outward.  In  the  neljrhborhood  of  this  pocket,  very  tine  whitish,  cloudy 
nieuibranes  in  tiie  otherwise  colorless  vitreous.  A  considerable  amount  of 
carbonate  of  lime  was  found  between  the  choroid  and  retina,  as  also  on  the 
inner  surface  of  the  ciliary  body,  just  as  in  the  above  mentioned  case,  ^'on 
Graefe  draws  attention  to  this  diffuse  process,  extending  from  the  ciliary  pro- 
cesses over  the  entire  choroid.  Owing  to  the  fact  that  the  new  formed  con- 
nective tissue  was  in  the  vitreous,  and  tlie  iris  was  not  involved,  this  should 
be  designated  as  a  chorio-cyclitis.  Tlic  case  of  A'on  Graefe.  which  was  ex- 
amined by  Iwanoff,  was  an  atrophied  eye.  as  a  result  of  reclination.  Here  it  ap- 
pears the  reclinated  portion  of  the  lens  was  resorbed.  The  entire  vitreous  had 
been  clianged  into  a  new  connective  tissue  mass  and  was  drawn  forward. 
Only  here  and  there  could  the  various  layers  be  distinguished  in  the  detached 
retina,  which  seemed  to  be  made  up  of  hyiiertrophied.  radiating  fibres.  The 
entire  choroid  was  folded,  and  between  this  and  the  retina  anteriorly  was  a 
thin  lamellae  of  bone.  Even  in  flue  sections  small  abscesses  could  be  detected 
in  the  vitreous.  The  sheath  of  connective  tissue  which  surrounded  the  lens 
seemed  to  be  very  tough,  and  at  some  places  enclosed  deposits  of  lime  salts. 
This  advanced  calcitication  seemed  remarkable,  considering  that  the  reclina- 
tion had  been  practiced  but  nine  months  previously.  The  processes  which  lead 
to  these  changes  is  to  be  designated  as  an  irido-clioroiditis. 

B. 
DISCISSION. 

As  a  rule,  but  slight  reaction  follows  discission  through  the  cornea; 
there  are,  however,  exceptions  to  the  rule. 

The  kind  of  instrument  used  to  puncture  the  cornea,  and  to  open 
the  capsule,  is  not  without  its  influence.  The  English  discission  needle 
which  is  now  in  general  use,  only  became  so  graduall}'.  This  is  straight, 
anteriorly  two-edged,  and  its  neck  has  everywhere  an  equal  thickneSvS,  so 
that,  when  during  the  operation  the  needle  is  either  pressed  forward  or 
drawn  backward,  it  always  completely  fills  out  the  channel  of  the  wound; 
and,  since  the  wound  made  by  the  double  edge  is  just  equal  to  the  diam- 
eter of  the  neck,  hence  it  is  impossible  for  the  aqueous  to  escape,  during  the 
operation.  The  older  instruments,  especially  those  which,  even  until  re- 
cently, were  recommended  by  some  Eliglish  physicians,  arc  conical  and 
increase  in  thickness.  This  instrument  not  only  interferes  with  the  free 
movement  in  the  channel  of  the  wound, but  its  use  certainly  favors  the  bruis- 
ing of  the  edges  of  the  wound.  Such  a  waund  will  leave  a  cicatrix,  which 
will  be  visible  for  a  much  longer  time.  In  exceptional  cases,  the  edges  of 
the  wound  have  been  observed  to  swell  up  and  assuuu^  a  bubble-like  promi- 
nence.    If  we  will  only  stop  to  consider,  how  kindly  frequently  repeated 


29  T 
punctures  of  the  anterior  clianiber  are  borne,  (.Sperino),  we  can  not  assume 
that  the  occasional  unfortunate  mishap?;,  are  entirely  the  result  of  the  cor- 
neal wound.  Here  again,  the  effect  of  an  infection,  either  direct,  by  ui^e  of 
a  non-sterile  instrunient.  or  the  siibse(|uent  infection  of  the  wound  from 
conjunctival  secretion,  is  to  be  l)orne  in  mind. 

If.  during  or  after  the  operation,   the  a(pit'()us  is  partially   or  com- 
pletely evacuated,  the  entire  lens  system  must  move  forward.     All  the  se- 
quelae of  this  occurrence,  the  release  of  the  blood  vessels  from  the  intra- 
ocular pressure,  and  the  consequent  hyperaemia,  in  all  the  vascular  portions 
of  the  eye,  as  well  as  the  tension  which  is  exerted  on  the  ciliarv  bodv  in 
consequence  of  this  moving  forward  of  the  lens,  must  be  looked  upon  under 
certain  circumstances  as  replete  with  injurious  effects.     It  is  well  known, 
that  puncture  of  the  anterior  chamber  during  the  course  of  inflammatory 
affections  of  the  eye.  is  accompanied  by  great  pain.     The  moving  forward 
of  the  entire  lens  system  depends  on  the  extent  of  the  wound  in  the  capsule, 
the  depth  to  which  the  needle  penetrates  the  lens  substance,  the  consistence 
and,  more  especially,  the  compactness  of  the  cataract.     If  one  may  so  ex- 
press it.  the  normal  process  of  absorption  of  the  lens,  after  opening  the 
capsule,  has  already  been  fully  described  in  the  general  consideration  of 
traumatic  cataract.    But  discission  does  not  always  follow  the  normal  course 
there  depicted,  for  symptoms  of  a  violent  reaction  may  develop.    The  pupil 
contracts,  and,  in  spite  of  the  free  use  of  atropine,  will  not  dilate.     The 
iris  becomes  discolored,  and,  owing  to  the  rapid  swelling  up  of  the  entire 
lens,  is  pushed  forward,  or  a  large  amount  of  lens  substance  enters  the  an- 
terior chamber  and  also  presses  the  iris  forward.      The   peri-corneal   in- 
fection which  develops  at  once,  gradually  leads  to  an  oedema  of  the  con- 
junctiva bulbi;  the  ej-es  become  hard,  and  the  field  of  vision  contracted  to 
the  nasal  side.     At  the  same  time,  the  patient  complains  of  irritability  to 
light,  and  intense  pain  radiating  along  the  branches  of  the  trigeminus. 
The  picture  of  secondary  glaucoma  is  complete. 

It  has  been  supposed  that  these  phenomena  are  the  result  of  opening 
the  capsule  too  widely,  and  of  permitting  the  needle  to  sink  too  deeply 
into  the  lens  substance;  nevertheless,  they  have  occurred  after  the  most  care- 
ful opening  of  the  capsule.  Hence,  either  the  eye  must  be  too  sensitive  or 
■  the  cataract  peculiarly  constituted  chemically,  so  as  to  exert  such  a  detri- 
mental influence.  But  the  increased  tension  is  always  brought  on  by  the 
rapid  swelling  up  of  the  lens;  this  leads  to  the  circulatory  disturbances,  the 
contraction  of  the  field  of  vision,  the  irritability  to  light  and  the  ciliary 
pain. 

"All  these   changes  are  almost  exclusively   obseived  in   the   eyes   of 
youthful  individuals,  except  in  cases  in  which  we  are  dealing  with  exten- 


29S 

sive  injury.  In  older  persons  the  opening  of  the  anterior  capsule  likewise 
leads  to  a  swelling  up  of  the  cortical  substance,  but  if  this  does  not  exceed 
reasonable  bounds,  it  will  not  lead  to  a  pressing  forward  of  the  entire  len- 
ticular mass,  which  does  not  seem  to  take  place  unless  the  nucleus  likewise 
swells  vip.'' 

These  words  of  Von  (Iraefe^  explain  why  injuries  of  the  lens  in  older 
individuals  have  a  better  prognosis  than  in  younger  individuals;  and  also 
why  in  the  latter  days  of  his  activity  he  became  more  careful  in  the  selec- 
tion of  cases,  in  which  he  practiced  discission.  If  we  are  to  look  upon  the 
great  swelling  of  the  cataract  as  the  cause  of  the  increased  intra-ocular  ten- 
sion and  its  evil  consequences,  it  must  become  evident,  that  if  the  swollen 
lens,  even  in  its  entirety  or  partially,  is  extracted  at  the  proper  time,  the 
pain,  as  a  rule,  will  cease  at  once,  the  chemosis  will  gradually  subside,  and 
the  resorption  of  any  portion  left  behind  will  take  a  regularly  normal 
course.  It  must,  however,  become  evident,  that  under  just  such  circum- 
stances a  thick  secondary  cataract  will  develop,  and  that  this  can  hardly 
take  place  without  the  formation  of  synechia. 

The  spastic  contraction  of  the  pupil  following  discission  is  caused  by 
a  swelling  up  of  the  lens,  which  condition  likewise  leads  to  increased  ten- 
sion, owing  to  the  interference  with  the  evacuation  of  the  swollen  lens  sub- 
stance into  the  anterior  chamber.  The  increase  of  tension  is  also  due  to 
increased  secretion  within  the  eye,  due  to  the  injury  to  the  lens.  Hence 
the  healing  influence  which  an  iridectomie,  made  either  at  the  time  of 
discission  or  previous  to  it,  exerts  on  the  course  of  the  discission,  can  be 
explained  in  two  ways.  Owing  to  the  incision  in  the  sphincter  pupillae, 
the  iris  loses  its  power  of  contraction,  and,  aside  from  this,  the  excision  of 
the  pieces  of  the  iris,  acts  just  as  it  does  in  true  glaucoma.  Hence  it  is 
most  advisable  to  make  the  extraction  of  a  swollen  lens  through  a  linear 
incision,  at  the  same  +ime  making  an  iridectomie  In  his  -ast  publication 
on  cataract.  Von  Graefe  spoke  in  the  highest  terms  of  praise  of  this  method 
of  treatment,  and  I  (Becker)  have  repeatedly  drawn  attention  to  the  same 
fact 

If  the  operation  made  during  the  stadium  glaucomatosum  is  not  made 
according  to  this  method,  advised  above,  in  most  cases  a  very  painful, 
"sneaking"  iridocyclitis  will  follow,  leading  to  occlusion  of  the  pupil  and 
phthisis  bitlhi.  In  such  cases  the  detachment  of  the  retina  usually  comes  on 
at  a  later  date.  For  a  long  time,  a  part  of  the  sensitiveness  to  light  remains, 
even  in  eyes  in  which  intra-ocular  tension  is  reduced. 

There  may  also  develop  primarily,  as  well  as  following  a  status  glaii- 

1  A.  f.  O..  I.  2.  p.  238. 


299 

coiinilosiis.  a   su[»|)uriilivc'  irido-c-lioroitlili.-.   ))aii(i|tllialiiiit i>,   willi    purulent 
destruction  of  the  eye. 

Where  a  discissio  per  scleroticam  is  made,  the  amount  of  vision  at- 
tained should  equal  that  attained  where  a  soft  lens  is  reelinated.  Hence  it 
will  be  unnecessary  to  again  consider  those  processes  which  have  already 
been  described,  and  which  make  the  results  of  such  an  operation  question- 
able. 

The  pathological  ])rocesses  wliich  iolluw  a  discission  have  been  prac- 
tically considered  under  the  head  of  traumatic  cataract.  Here  we  must 
again  refer  to  the  experimental  investigations  of  Dietrich  and  Ritter.  How- 
ever, to  give  a  synopsis  of  their  work,  wouhl  l)o  Init  to  repeat  many  facts 
which  have  already  been  quoted. 

Swanzy  (Diseases  of  the  Eye.  London,  189-^,  p.  360)  states.  ''This 
method  is  applicable  to  all  complete  cataracts  up  to  the  twenty-fifth  year, 
and  to  those  lamellar  cataracts  in  which  the  opacity  approaches  so  close  to 
the  periphery  of  the  lens,  that  nothing  can  be  gained  by  an  irideetomie. 
After  the  above  age,  the  increasing  hardness  of  the  nucleus,  and  the  in- 
creasing irritability  of  the  iris  render  the  method  unsuitable." 

"Discission  is  a  safe  procedure  when  used  with  the  above  indications 
and  precautions.  The  danger  chiefly  to  be  feared  is  iritis,  from  pressure 
of  the  swelling  lens,  masses  on  the  iris.  When  this  occurs,  or  is  threatened, 
removal  of  the  cataract  by  linear  incision  in  the  cornea  should  be  at  once 
performed.  Another  danger  consists  in  the  glaucouuitous  increase  of  ten- 
sion (secondary  glaucoma):  here,  likewise,  removal  by  a  linear  incision  is  at 
once  indicated." 

C. 

EXTRACTION. 

As  we  have  seen,  tlu-  original  Daviel  extraction  consisted  of  a  corneal 
■flap  ((h)iritirard),  taking  in  tiro-thirds  of  the  corneal  circumference,  and 
without  an  irideetomie.  The  only  change  up  to  the  time  of  Von  Graefe 
consisted  in  the  position  of  the  wound  (Yaeger,  iijiironl:  W'enzel.  oiilirard). 
But  the  principal  objection  to  this  operation  always  had  been,  the  rela- 
tively large  percentage  of  losses  as  the  result  of  suppuration.  Yon  Graefe 
early  recognized  that  this  was  due  to  the.  at  times,  unnecessary  gaping  of 
the  wound,  to  overcome  which  lu'  iiitidduced  what  i>  known  as  the  linear 
incision.  Such  an  incision  can  only  he  done,  when  the  inc-ision  is  made  in 
the  "largest  circle"*  of  the  s])herical  surface  of  the  eye.  because  the  shortest 
distance  between  points  u])on  the  surface  of  the  sphere,  i.  e.,  the  line  which 
is  most  nearly  straight  falls  in  the  largest  circle.  The  largest  circle  which 
passes  through  two  points  on  the  surface  of  a  sphere,  is  situated  in  a  plane 


300 

passing  through  tliese  points  and  the  centre  of  the  sphere.  In  order  to 
make  this  incision,  a  much  narrower  knife  was  necessary',  and  this  Graefe 
likewise  invented,  and  this  today  bears  his  name.  This  incision  was  like- 
wise made  in  the  cornea,  but  in  order  to  allow  the  lens  to  escape  easily  the 
preparatory  iriiieciomie  was  made.  Jacobson  made  his  incision  in  the 
sdero-corneal  mar(/in,  and  this  suggestion  was  adopted  by  Von  (Jraefe  add- 
ing to  this  an  ocular  conjunctival  flap  which  acted  as  a  provisional  band- 
age. 'J'his  is  known  as  his  peripheral  linear  incision,  and  was  in  vogue  dur- 
ing his  lifetime.  After  his  death,  however,  operators  gi*adually  departed 
from  this  operation,  going  back  to  the  flap  extraction,  one  set  of  operators 
making  what  is  known  as  the  scleral  flap  extraction.  In  this  operation,  the 
puncture  and  counter-puncture  are  made  in  the  sclera  one-half  mm.  from 
the  corneal  margin,  and  in  such  a  manner  that  a  straight  line  connecting 
these  two  points  would  separate  the  upper  foui-fh  from  the  lower  three- 
tonrths  of  the' corneal  circumference.  After  the  counter-puncture  is  made, 
the  incision  lies  close  behind  the  limbus.  As  soon  as  the  sclera  is  severed, 
the  edge  of  the  blade  is  turned  slightly  backward,  so  as  to  form  a  conjunc- 
tival flap,  about  2  mm.  in  width.  The  irid£ctomie,  capsulotomy,  and  ex- 
traction of  the  lens  follows.  The  great  advantage  of  this  operation  lies  in 
the  fact,  that  the  incision  lies  under  the  conjunctiva,  which  latter  also 
forms  a  tla]).  which  soon  closes  over  the  wound  again,  and  thus  prevents 
s uhseqiient  infection . 

A  second  form  of  operation  is  the  corneal  flap  extraction,  (Wecker, 
Stellwag).  Here  the  entire  incision  is  made  in  the  corneal  limbus  and  in 
such  a  manner  that  one-third  of  the  cornea  is  separated  from  the  sclera. 
In  this  operation  no  conjunctival  flap  is  obtained;  or,  if  any,  but  a  very 
slight  one.  llie  iridectoniie  may  or  need  not  he  made,  depending  on  the 
desire  of  the  operator.  Fuchs  says,  (Lehrbuch,  1891,  p.  T59),  "Since  this 
incision  is  less  peripheric,  i)rolapse  of  the  iris  is  less  apt  to  occur,  than  where 
a  scleral  incision  is  made.  Whereas,  when  no  iridectomie  is  made,  the 
patient  has  the  advantage  of  a  round  and  movable  pupil,  it  also  brings  with 
it  its  disadvantages:  First,  the  delivery  of  the  lens  without  an  iridectomie 
is  more  diflficult,  since  it  must  be  forced  througli  a  narrow  pupil,  which 
procedure  requires  considerable  pressure.  Hence,  this  method  is  not  indi- 
cated in  cases  which  depend  on  a  very  delicate  delivery  of  the  lens,  as,  per 
example,  whore  the  lens  trembles  and  every  increase  of  pressure  is  apt  to 
lead  1(1  tearing  (»!'  tlie  zonula  and  the  liyaloi(h'a.  and  at  the  same  time  lead 
to  a  prolapse  of  the  vitreous.  Second,  extraction  without  iridectomie  is 
not  advisable  in  complicated  cataracts,  in  which  synechia  exist  between 
lens  and  iris.  Third,  notwithstanding  the  use  of  eserine,  prolapse  of  the 
iris  niav  ot(  iii'  in  the  first  few  days  after  an  operation.     Under  such  cir- 


30I 

cumstances  the  prolapsed  iris  u\u>t  ho  excised.  Ilenee,  extraction  without 
iridectomie  is  not  indicated  in  cases  wliicli  show  a  tendency  to  prolapse  of 
the  iris,  or  where  the  patient  is  restless.  Hence,  one  may  conclude  that 
the  corneal  flap  extraction,  where  the  conditions  ar.  favorable,  gives  the 
most  satisfactory  results;  it  is.  liowever.  not  adapted  to  all  cases,  nor  does  it 
insure  those  almost  positive  results,  as  does  the  scleral  extraction  with  iri- 
dectomie." Swanzy  (Handbook.  Fourth  Edition,  181)<i,  p.  :}r)5)  states,  ''As 
a  set-off  against  the  circular  pupil,  the  extraction  without  iridectomie  ex- 
poses the  eye  to  the  serious  danger  of  prolapse  of  the  iris  into  the  wound. 
These  operators  make  it  a  rule  to  perform  an  iridectomie  in  all  cases  where 
they  can  not  satisfactorily  repose  the  ii-is  after  delivery  of  the  lens;  but 
even  where  they  can  repose  it  well,  they  are  not,  they  state,  secure  against 
the  occun-ence  of  a  prolapse  within  the  first  two  or  three  days  after  the 
operation;  nor  do  they  find  that  eserine,  or  any  other  means,  provides  the 
desired  safeguard.  It  is  adm'itted  that  prolapse  of  the  iris  takes  place  after 
a  number  of  these  operations,  and  that  there  is  no  foretelling  in  what  eyes 
it  will  occur.  The  prolapsed  portion  of  the  iris  heals  in  the  wound,  which 
then,  in  a  few  weeks,  becomes  more  or  less  cystoid  and  bulging,  causing 
displacement  of  the  pupil,  and  irregnlar  curvature  of  the  cornea,  with  re- 
sulting deterioration  of  vision.  Xor  is  this  all:  for  such  eyes  are  liable, 
weeks,  months,  or  even  years  after  the  operation,  to  take  on  severe  irido- 
cvclitis,  ending  in  total  loss  of  sight.  Another  disadvantage  of  this  opera- 
tion is,  that  removal  of  cortical  remains  can  not  be  so  effectually  performed, 
as  where  a  coloboma  has  been  made.'' 

"Therefore,  while  admitting  the  charm  of  a  circular  pupil.  I  am  of 
opinion,  that  the  question  is  not,  whether  the  appearance  of  some  eyes 
operated  on  is  pleasing  to  us,  and  to  others  who  inspect  them;  but  rather, 
what  advantage  the  greatest  number  of  persons  operated  on  derive  from  the 
operations.  With  sentimental  talk  about  ''mutilation"  of  the  iris,  I  can  not 
sympathize.  If  the  advocates  of  the  method  under  discussion  should  find 
it  means  of  insuring  the  eye  against  prolapse  of  the  iris,  the  operation  will 
be  placed  upon  a  different  footing:  but.  nntil  then,  the  procedure  can  not, 
1  think,  be  recommended.'' 

"It  is  easy  to  understand  why,  in  the  simple  extraction  prolapse  of 
the  iris,  with  subsequent  incarceration,  is  so  liable  to  occur,  even  some 
days  after  the  operation,  and  why  it  is  so  difficult  to  devise  a  sure  means  for 
preventing  the  accident;  as,  also,  how  it  is  that  even  a  very  narrow  colo- 
boma is  sufficient  to  protect  the  eye  from  the  disaster.  And  yet  I  am  in- 
clined to  think,  that  among  the  oculists  who  have  reverted  to  the  simple 
method,  there  are  some  who  do  not  reahze  the  modus  operandi  in  either 
case.     Within  a  few  hours  after  the  operation,  the  wound  in  the  corneal 


302 

margin  most  commonly  closes,  the  aqueous  humor  collects,  and  the  anterior 
chamber  is  restored.  But  it  takes  many  hours  more  for  the  delicate  union 
of  the  lips  of  the  wound  to  become  quite  consolidated,  and  during  that  time 
it  requires  but  little — a  cough,  a  sneeze,  a  motion  of  the  head,  the  necessary 
efforts  in  the  use  of  a  urinal  or  bed-pan,  no  matter  how  careful  the  nursing 
— to  rupture  the  newly  formed  union;  and,  as  a  matter  of  fact,  this  often 
does  take  place.  The  aqueous  then  flows  away  through  the  wound  with  a 
sudden  gush,  and,  where  the  simple  extraction  has  been  employed,  carries 
with  it  the  iris.  Doubtless,  in  this  event,  it  is  that  portion  of  the  aqueous 
humor  which  is  situated  behind  the  iris,  which  is  chiefly  concerned  in  the 
iris  prolapse;  the  aqueous  humor  in  the  anterior  part  of  the  anterior  cham- 
ber probably  flows  off  without  influencing  the  position  of  the  iris.  The 
advocates  of  the  simple  operation  endeavor  to  prevent  secondary  iris-pro- 
lapse, by  a  spastic  contraction  of  the  pupil,  produced  by  eserine,  which  is 
instilled  at  the  conclusion  of  the  operation,  and  again,  by  some  operators,  a 
few  hours  afterward.  In  most  instances,  the  desired  end  is  by  this  means 
effected." 

"But  there  is  a  considerable  percentage  of  cases  in  which  the  contrac- 
tion of  the  sphincter  iridis  is  overcome  by  the  pressure  of  the  aqueous 
humour  from  behind,  and  iris  prolapse  takes  place." 

"How,  then,  does  the  formation  of  a  coloboma  prevent  prolapse  of  the 
iris  when  the  wound  bursts,  as  I  have  described?  Not  because  the  portion 
of  the  iris  which  is  liable  to  prolapse  has  been  taken  away.  That  would 
mean  nothing  less  than  the  whole  of  the  part  of  the  iris  which  corresponds 
to  the  length  of  the  opening  in  the  corneal  margin.  But  the  coloboma 
averts  secondary  iris-prolapse,  because  it  provides  a  gateway,  a  sluice,  for 
the  aqueous  humor  contained  in  the  posterior  part  of  the  anterior  chamber, 
to  escape  directly  through  the  wound,  without  carrying  with  it  the  iris  in 
its  rush;  and  it  is  evident,  that  the  narrowest  coloboma  which  can  be 
formed  will  be  amply  sufficient  for  the  purpose.  To  my  mind,  a  narrow 
iridectomie  here  is  no  "mutilation  of  the  iris,"  but  rather  a  measure  which 
rests  upon' a  sound  scientific  basis,  and  which  is  calculated  to  insure  the 
safety  of  the  eye  in  an  important  particular." 

"As  a  disfigurement  of  the  eye,  there  is  practically  none,  when  the 
coloboma  is  so  narrow,  and  is  situated  in  the  upper  ))art  of  the  iris.  The 
pupil,  too,  is  movable;  almost,  if  not  quite,  as  much  so,  I  venture  to  say, 
as  in  most  cases  of  simple  extraction.  For  it  is  entirely  a  mistake  to  sup- 
pose that  a  narrow  coloboma  renders  the  pupil  immovable.  Where  there 
are  no  adhesions  between  the  pupillary  margin  and  the  capsule,  as  fre- 
quently happens,  the  reaction  to  light  is  active;  a  drop  of  atropine  will 
dilate  the  pupil  widely,  and  a  drop  of  eserine  will  contract  it." 


303 
Naturally,  every  incision  in\ist  be  of  sufficient  size  to  permit  the  cata- 
ractons  lens,  whose  horizontal  section  is  an  ellipse,  to  emerge  conveniently. 
Schmidt-Kimpler  states,^  "In  the  flap  incision,  extraction  is  performed  by 
bending  the  flap  of  the  cornea  away  from  the  sclera.  The  length  of  the 
incision  must  here  approximate  the  diameter  of  the  cataract  from  right  to 
left;  for  example,  8  to  9  mm.,  while  the  height  of  the  flap  must  at  least 
equal  the  antero-posterior  diameter  of  the  cataract;  for  example,  3  to  4  mm. 
If  we  assume  the  horizontal  transverse  diameter  of  the  transparent  cornea 
— excluding  the  sclera  limbus,  which  can  be  moved  over  about  0.5  mm. 
on  each  side — at  11  mm.,  height  of  the  flap  above,  5  mm.;  a  flap  incision 
made  here  would  even  exceed  the  dimensions  of  the  largest  cataract.  But 
it  must  be  remembered  that  the  size  of  the  wound  in  the  membrana  des- 
cemeti  (inner  corneal  w^ound)  is  somewhat  smaller  than  that  in  the  outer 
corneal  layer  (external  corneal  wound).  If  the  cataract  is  to  pass  through 
a  linear  incision,  the  latter  must  be  made  to  gape.  This  is  done  by  bring- 
ing the  ends  somewhat  closer  together,  so  that  an  ellipsoidal  opening  is 
formed.  The  length  of  the  incision  must  therefore  be  greater  than  the 
diameter  of  the  lens  from  right  to  left.  Its  size  is  determined  when  we 
know  the  circumference  (u)  of  the  ellipse  necessary  for  the  passage  of  the 

lens.    It  equals  — ,  where  "a"  is  the  smallest  diiimeter;  ''b"  the  largest 

diameter  of  the  ellipse.  If  the  cataract  is  4  mm.  in  thickness,  and  9  mm. 
in  diameter,  17=^-^^^^^=6.5+3.14=2.041.     The  linear  incision,  which  is 

2 

to  be  converted  into  an  ellipse  by  the  approximation  of  its  ends,  must  there- 
fore, be  half  as  long,  or  about  10  mm.-  (In  this  calculation,  we  disregard 
the  fact  that  we  have  to  deal  with  ellipses  or  incisions,  not  upon  a  plane, 
but  upon  a  spherical  surface).  A  linear  incision  of  such  length  can  only 
be  made  by  passing  through  the  transparent  corneal  tissue.  If  the  incision 
is  made  in  great  part  in  the  edge  of  the  cornea,  as  is  usually  done,  we  must 
abandon  an  absolutely  linear  character;  the  majority  of  so-called  linear  in- 
cisions are  really  flap  incisions,  although  of  small  flap  height.  It  is  to  be 
regarded  as  a  special  advantijge  of  linear  incisions,  that  they  have  a  less 
tendency  to  gape,  than  flap  incisions;  strong  intra-ocular  pressure  is  capable 
of  lifting  up  the  flaps." 

"The  length  of  the  incision  must  depend  on  the  size  and  consistence 
of  the  cataract.  Thus,  a  soft  cortical  cataract,  which  is  displaced  during 
extraction  and  changes  its  shape  according  to  the  wound,  requires  a  smaller 
opening  than  a  hard  cataract.     The  size  of  the  nucleus  is  also  import<int."' 

Ph.  Steffan  '^  has  given  us  a  very  interesting  table  of  measurements  of 

2  Handbook,  1889.    English  edition,  p.  326. 

SWeitere  Erfahrungeu  und  Studien  iiber  die  Kataract  Extraction.  1SS2-1889. 
Graefe  Arch..  Vol.  XXXV,  B.  2.    1889. 


304 

500  extracted  cataracts.  But  13  per  cent,  of  these  luul  a  maximal  diameter 
of  8.5-9.0  mm.  and  a  thickness  of  4  mm.:  further,  vvlierea.s,  after  the  forty- 
fifth  year,  we  must  be  prepared  to  find  the  maximal  size,  up  to  the  forty- 
fourth  year  the  diameter  equals  8  mm.  and  a  thickness  of  ;5  nnu. 


_.             o 

. 

1 

Mean 

Diam.     rt  • 
ofCa-     fcu 

30-34 

35-39 

40-44 

45-49 

50-54 

55-59 

60-64 

65-69 

70-74 

75-79  80-84 

85-89      T.f.l 

thick- 
of  the 
Cata- 
ract. 

taract  ;  -o  S 
in  mm.    S^> 

Yrs. 

Yrs. 

Yr.s. 

Yrs. 

Yrs. 

Yrs. 

Yrs. 

Yrs. 

Yrs. 

Yrs    Yrs. 

Yr.s. 

■ 

5-5-60 

I 

, 

I 

2 

I 

6=2  f* 

6.5-7 

5 

4 

7 

10 

13 

23 

21 

14 

II 

2 

110=2254 

3  mm. 

7-5-8 

3 

4 

16 

38 

47 

71 

76 

35 

21 

5 

5 

320-64  ^i 

&5-9 

3 

2 

5 

6 

15 

12 

5 

Iff  the 

capsule 

3 

2 

I 

3 

' 

5 

2 

^ 

"1,.: 

4  mm. 

Hirschberg  (quoted  above)  states,  "In  order  to  attain  good  results  in 
cataract  extraction,  three  things  are  necessai7;  care  before  the  operation, 
care  during  the  operation,  care  after  the  operation.  The  two  greatest  at- 
tainments of  modern  surgery,  namely,  anaesthesia  and  antisepsis  (new, 
asepsis),  have  not  failed  to  bear  fruit  in  opthalmology."' 

The  patient  should  never  be  operated  on  the  day  of  his  admission  to 
the  hospital.  One  day  of  preparation  is  sufficient;  to  wait  longer,  causes 
the  patient  to  become  impatient,  and  this  is  detrimental. 

The  day  previous  to  operation  the  patient  receives  a  dose  of  oleum 
ricini  (or  some  other  luxative)  and  in  the  evening  a  light  repast.  The  day 
of  the  operation,  three  hours  previous  to  the  same,  a  cup  of  coffee  (or  milk; 
without  bread;  and,  subsequent  to  the  operation,  during  the  first  few  days, 
a  bland  diet  which  does  not  require  much  mastication  and  produces  but 
little  faecal  matter;  hence,  during  the  first  four  or  five  days  during  which 
the  patient  is  confined  to  bed,  there  is  seldom  a  desire  to  empty  the  recium. 
Finally,  the  evening  previous  to  the  o])eration,  the  patient  receives  a  luke- 
warm bath,  especial  attention  being  given  to  a  thorough  washing  of  the 
head. 

The  operation  is  to  be  done  in  a  well-lighted  room,  the  best  light  being 
the  north  light. 

The  operatoj-"s  hands  are  to  be  thoroughly  washed  with  soap  and  water, 
washed  in  subhmate  1:1000  and  alcohol,  and  the  finger  nails  cleaned  with 
nail  brush  and  file. 

The  instruments  are  to  be  tested  by  the  operator  himself.  All  instru- 
ments which  enter  the  eye  must  be  made  thoroughly  aseptic.  Boiling  water 
destroys  the  pns- form rrs,  so  that  instruments  which  are  kept  clean  may  be 
considered  sterile,  after  being  ])hu-e(l  in  l)()iliiig  water  for  one-half  to  one 
minute.  All  glass  or  porcelain  utensils  are  to  be  previously  cleansed  in  a 
1:1000  sublimate  sol.     All    glasses,  dishes    and    droppers    are    previously 


305 
placed  in  a  1:1000  sublimate  sol.,  and  jjiepared  fresh  for  each  patient,  and 
just  previous  to  the  operation  are  washed  out  in  a  warm  1:5000  sublimate 
sol.  The  three  fluids  (absolute  alcohol.  IXii  jxt  cent.;  sublimate  water, 
1:1000,  and  sublimate  water,  1:5000)  are  kept  in  well-stopped  bottles.  A 
small  bottle  of  a  5  per  cent,  cocaine  sol.  is  prepared  fresh,  just  prior  to  the 
operation. 

The  operations  arc  always  done  early  in  the  inornin«i-,  for  to  do  such 
delicate  operating  the  operator  should  feel  fresh.  Knapi),^*  however,  be- 
lieves it  better  for  tlie  patient  to  be  operated  in  the  afternoon,  because  the 
usual  five  or  six  hours  of  smarting  will  then  be  followed  by  an  undisturbed 
sleep,  during  which  the  union  of  tlie  wound  has  the  best  chance  to  take 
place  and  become  permanent. 

With  a  sterilized  dropper,  at  intervals  of  five  minutes  cocaine  is 
dropped  into  the  eye  three  or  four  times.  (When  the  iridectomie  is  made, 
four  times  is  sufficient:  tlie  touching  of  the  iris  with  the  forceps  will 
scarcely  be  felt). 

During  the  intervals  in  which  the  cocaine  is  being  dropped  into  the 
eye,  the  lids  should  remain  closed.  Immediately  after  the  last  drop  has 
been  dropped  into  the  eye,  the  lids  and  conjunctiva  are  to  be  carefully 
washed  with  absorbent  cotton  and  fresh  subhmate  water,  and  then  dried. 
The  patient  is  then  placed  horizontally  on  the  operating  table,  with  the 
head  slightly  raised.  An  assistant  holds  the  head,  his  one  hand  on  the 
temple  on  the  side  opposite  the  operator,  and  tlie  other  on  the  forehead. 
(A  nurse  usually  liolds  the  patient's  hands.) 

The  eye  which  is  to  be  operated,  is  placed  toward  the  window.  The 
operator,  who  always  operates  with  his  right  hand,  sits  behind  the  patient 
when  operating  the  i-ight  eye,  and  in  front  of  the  patient  when  operating 
his  left. 

A  short  speculum,  one  which  separates  the  lids  v>idely  and  keeps  them 
at  a  good  distance  from  the  eye,  but  which  opens  and  closes  easily,  is  then 
introduced;  the  screw,  however,  should  never  be  clo.^ed,  .«o  that  it  may  be 
removed  quickly  by  a  single  movement  at  any  time;  ;.nd  which,  as  a  rule, 
is  done  immediately  after  cystotomie,  and  in  exceptional  cases  where  the 
patient  presses  very  hard,  even  before  the  iridectomit . 

With  the  left  hand,  the  operator  now  takes  a  short  pair  of  fixation  for- 
ceps with  a  spring  to  close  tlu'ni.  and  with  tliese  grasos  a  fold  of  the  ocular 
conjunctiva  just  below  the  horizontal  meridian.  In  his  right  hand  he  takes 
his  cataract  knife,  which  is  li  mm.  in  width:  this  k  delicately  held,  like  a 
pen,  the  cutting  edge  naturally  upward,  toward  the  ujipcr  corneal  margin. 


3a  N orris  and  Oliver  System  of  Diseases  of  Eye.  Vol.   III.  p.  Tfn 


3o6 

In  this  manner,  the  anterior  chamber  is  punctured,  s  >  that  the  back  of  the 
knife  separates  one-third  of  the  corneal  circumference.  (The  pulling  down- 
ward of  the  e5'eball  by  means  of  the  fixation  forceps,  as  well  as  the  pointing 
of  the  knife  toward  the  centre  of  the  pupil,  as  advised  by  Von  Graefe,  are 
unnecessary,  and.  if  anything,  detrimental.)  The  cocainized  eye  is  com- 
pletely toleran^  to  the  fixation  forceps,  so  that  one  may  at  once  make  punc- 
ture with  the  cataract  knife.  The  practiced  eye  will  at  once  see  at  a  glance 
whether  the  width  of  the  pupil  is  equal  to  one-fourth  or  one-third  of  the 
heiglit  ot  the  cornea,  (3  or  4  mm.);  hence,  whether  the  edge  of  the  knife 
should  be  tangent  to  the  upper  edge  of  the  pupil  or  a  mm.  below  this;  and 
•  along  this  line  the  knife  reaches  the  symmetrical  point  opposite  to  that  of 
its  entrance  into  the  anterior  chamber,  in  order  to  gain  the  correct  point  of 
contra-puncture;  the  handle  of  the  knife  is  depressed  slightly  toward  the 
temple,  and  then  the  point  of  the  knife  is  pushed  forward  a  few  milometres. 
The  handle  of  the  knife  is  then  made  to  make  a  quarter  turn  on  its  axis,  so 
that  the  cutting  edge  comes  against  the  posterior  surface  of  the  cornea,  and 
then,  by  means  of  a  slight  sawing  motion,  the  corneal  incision  is  completed, 
the  line  of  the  incision  falling  close  to  the  limbus. 

The  assistant,,  who  sits  or  stands  on  the  opposite  side  of  the  operator, 
takes  the  fixation  forceps  out  of  the  operator's  hand  from  beneath  the 
operator's  hand,  and  holds  them.  The  operator  lays  his  cataract  knife  on 
the  porcelain  plate  at  his  side,  and  takes  up  the  curved  iris  forceps  with 
his  left  hand,  the  scissors  with  his  right.  (The  instruments  are  often 
handed  to  the  operator  by  an  assistant).  The  iris  almost  never  prolapses, 
but  in  the  exceptional  cases  it  is  first  carefully  replaced,  after  waiting  a  few 
moments  to  see  if  it  does  not  do  so  itself.  The  curved  iris  forceps  is  then 
introduced,  dosed,  at  the  centre  of  the  incision  in  a  radial  direction,  and 
opened  a  few  milometres  from  the  edge  of  the  sphincter;  and  iris  fold  is 
grasped,  withdrawn,  and  cut  off  by  a  single  clip  of  the  scissors.  Since  the 
introduction  of  cocaine,  bleeding  from  the  iris  almost  never  occurs;  the  in- 
cision in  the  globe  likewise  never  bleeds,  since  it  is  made  entirely  in  the 
cornea,  and  the  conjunctival  flap  given  up.  As  a  rule,  the  coloboma  is 
small,  with  converging  or  parallel  edges;  its  definite  form,  however,  is  de- 
]>endent  on  the  exit  of  the  lens. 

The  assistant  now  carefully  opens  the  spring  on  the  fixation  forceps; 
at  the  same  time,  the  speculum  is  gently  closed,  and  while  the  patient  is 
being  told  to  slowly  look  downward,  these  are  also  removed.  The  assistant 
now  gently  holds  the  lids  apart,  far  enough  to  expose  the  entire  cornea. 
Thereupon,  the  operator  again  clasps  the  ocular  conjunctiva  exactly  the 
vertical  meridian,  with  a  pair  of  forceps  held  in  the  left  hand,  while  in  his 
rjtrht  hand  he  takes  the  cvstitome   (the  hook  of  which  is  lon.o;tM-  and  sharper 


307 

llian  in  the  original  (iniclV  niodci.  wlici'cas  the  straijilit  portion  is  sliorter). 
With  this,  a  T-shapod  incision  is  made  in  the  capsule;  the  horizontal  por- 
tion first,  and  this  is  made  to  lie  in  the  coloboma.  Finally,  the  operator  re- 
verses the  instrument,  and  with  the  convex  surface  of  the  rubber  spoon  (or 
metal),  makes  gentle  pressure  on  the  external  lower  portion  of  the  cornea, 
whereupon  the  lens  rises  up,  during  which  time  the  spoon  slowly  follows, 
until  the  lens  is  totally  dehvered.  The  patient  is  lold  to  close  his  eyes, 
and  the  operation  is  practically  completed. 

Where  the  operaiion  is  made  withoiil  the  ivideetoniy,  Knapp  lays  par- 
ticular sii'css  on  the  mannci'  in  wliicli  ihc  cajtsule  is  to  be  opened.  He 
says:  "The  cvvtotome  so  advaiucs  I  hat  the  tip  goes  underneath  the  upper 
part  of  the  iris,  turn.-  it,  <ind  with  the  tooth  makes  the  incision  into  the 
ujiper  part  of  the  capsule,  parallel  witli  with  the  corneal  section,  about 
G.T  mm.  in  extent.  As  soon  as  the  (•a])sule  is  opened,  the  lens  nuikes  a 
visible  forward  motion.  Then  the  cystotome  is  withdrawn  again  with  the 
knee  forwai'd.  so  that  the  ])oint  does  not  injure  the  iris."  ^ 

Today  the  operation  requires  scarcely  as  much  time  as  it  does  to  read 
its  description;  less  than  one  minute,  when  the  preparatory  iridectomie  has 
been  made;  less  than  two  minutes  for  the  complete  operation. 

The  operator  holds  a  small  pledget  of  cotton,  which  has  been  dipped 
in  sublimate  water,  for  a  few  moments  over  the  patient's  eyelids,  and  then 
the  patient  looking  downward,  by  slight  pressure  "on  the  lower  lid,  which 
pressure  is  transmitted  to  the  cornea,  the  cortical  remains  are  removed. 
This  gentle  massage  also  aids  in  replacing  the  iris  in  its  proper  position. 
After  the  cystotomie,  the  entrance  of  any  instrument  into  the  eye  should  be 
avoided.  True,  one  should  always  have  the  blunt  spatula  and  the  Weber's 
Loop  close  at  hand  on  the  porcelain  dish,  but  they  seldom  are  called  into 
use.  A  small  pair  of  scissors  should  also  be  at  hand  to  enlarge  the  wound,  if 
the  contra-puncture  should  happen  to  be  too  far  in  the  cornea;  and  if,  on 
gentle  pressure  with  the  spoon,  the  lens  does  not  present  itself.  After  the 
operation, the  wound  which  should  coa|)t  well, be  smooth  and  free  from  coag- 
ula,  is  irrigated  with  a  sublimate  sol.  1:5000;  likewise,  the  entire  conjuncti 
val  sac.  The  eye  is  then  covered  with  an  aseptic  dressing,  and,  together 
wit])  the  non-operated  eye,  is  l)ouii(l  uj).*' 

The  after  treatment  is  very  simple.  The  after  pains  are  very  slight 
since  the  use  of  cocaine,  and  especially  where  mild  antiseptics  are  used. 
The  first  dressing  is  removed  at  the  end  of  twent3^-four  hours.    During  the 


a  System  (if  Diseases  of  Eye.    Norris  &  Oliver.     \u\.  :',.  \>.  T'.ts. 
b  Modern  operators  apply  a  simple  broad  dressing,  held  in  plaee  by  strips  of 
eourt-plMsler. 


3o8 

first  and  second  days,  a  dose  of  chloral  hydrate  Is  given,  and  tlie  nurse  is 
especially  watchful.  The  bandage  is  renewea  each  day  until  the  twelfth 
day,  but  the  patient  is  not  permitted  to  touch  the  eye. 

At  each  removal  of  the  dressing,  the  lids  are  first  gently  washed  with 
pledgets  of  cotton  dipped  in  sublimate  water.  Atropine  is  not  used  before 
the  first  day,  and,  in  faci.  only  then  when  there  are  cortical  remains  or 
irritability  of  the  iris.^" 

•'Reaction  seldom  follows.  The  two  principal  forms  are  iritis,  due  to 
swelling  up  of  cortical  remains,  and  septic  infection,  which  nearly  always 
leads  to  destruction  of  the  operated  eye,  and  can  but  seldom  be  stayed." 

•'THE  LIXEA'E  EXTRACTIOX  is  only  adapted  to  soft  and  fluid 
cataracts  in  young  persons.  Here  the  incision  is  made  with  a  l)road  lance- 
shaped  iridectomie  knife,  either  in  the  outer  horizontal  or  the  lower  outer 
quadrant.  The  knife  penetrates  about  4  mm.  from  the  corneal  margin,  and 
is  pressed  forw^ard  in  the  plane  of  the  iris,  until  the  corneal  incision  ha? 
attained  a  width  of  G  or  7  mm.  The  point  of  the  knife  being  now  laid  close 
to  the  posterior  surface  of  the  cornea — in  order  that  no  injury  may  be  done 
to  the  iris  or  lens,  when  the  aqueous  humour  commences  to  flow  ojffi — the 
instrument  is  very  slowly  withdrawn,  so  that  the  aqueous  humour  may 
come  away  gradually  without  causing  prolapse  of  th'^  iris.  In  withdrawing 
the  knife,  it  is  well  to  enlarge  the  inner  aspect  of  one  or  the  other  end  of 
the  wound,  by  suitable  motion  of  the  instrument  in  thai,  direction. 

The  knife  being  now  put  aside,  the  cystitome  is  passed  into  the  an- 
terior chamber  as  far  as  the  opposite  pupillary  margin,  care  being  taken,  by 
keeping  the  sharp  point  of  the  instrument  directed  either  up  or  down,  not 
to  entangle  it  in  the  wound  or  in  the  iris.  The  point  is  now  turned  directly 
en  the  anterior  capsule,  and  by  withdrawing  the  cystotome  toward  the 
corneal  incision,  an  opening  in  the  capsule  of  the  width  of  the  ])upil  is 
produced.  The  cystotome  is  then  removed  from  the  anterior  chamber  with 
the  same  precaution  as  on  its  entrance. 

The  edge  of  the  spoon  is  then  placed  on  the  outer  lip  of  the  corneal 
incision,  and  the  latter  is  made  to  gape  somewhat,  gentle  pressure  being  at 
the  same  time  applied  to  the  inner  aspect  of  the  eye  by  the  fixation  forceps 
and  in  lliis  way  tlie  lens  is  evacuated.  When  the  ])ui)il  has  become  quite 
black,  the  operation  is  concluded.  If  pressure  does  not  at  first  clear  the 
])upil  completely,  the  s{)eculum  should  l)e  removed,  the  eyelids  closed,  a 
compress  applied,  and  a  few  minutes  allowed  to  elapse,  in  order  that  some 
aqueous  be  secreted.  A  renewal  of  the  eH'ort  to  clear  the  pupil  will  prob- 
ably now  be  successful;  if  not,  another  pause  may  be  made,  and  then  fresh 
attempts  employed,  until  the  pupil  is  quite  clear.  It  is  unwise  to  insert  the 
spoon  into  the  eye  to  withdiaw  tlie  frn.aineiits:  and.  if  some  of  these  should 


309 
be  left  bcliiiul.  iio  ill  I'cstilts  need  iicccssaiily  follow,  iill  lioii^Mi  iritis  is 
more  apt  to  supervctu'  than  il'  the  lens  he  thoi'oucrlily  evacuaicd.  l-'rag- 
inents  left  behind  beioin'j  absorbed.  If  there  he  a,  prolapse  of  the  iris  which 
can  not  be  reposed,  it  must  be  abscised."   (Swanzy,  p.  33(5.) 

This  same  operation  is  applicable  to  nienibranous  cataracts,  with  a 
sharp-pointed  hook  or  forceps,  which  is  ])assed  through  the  wound;  the 
membrane  is  grasped  and  withdrawn.  The  advantages  of  this 
incision  consist  in  its  relatively  small  size,  and  the  readiness  with 
which  it  closes.  Xo  iridectomie  is  necessary.  Tmt,  owing  to  the  size 
of  the  corneal  incision,  this  operation  is  only  applicable  to  the  membranous 
and  soft  cataracts;  that  is,  in  those  which  do  not  possi'ss  a  nucleus. 

By  increasing  the  size  of  this  original  linear  incision,  moving  it  back 
farther,  and  making  it  above  and  combining  it  Avith  an  iridectomie,  Von 
Graefe  originated  his  peripheral  linear  incisiov.  But  this  incision  was  often 
too  small,  so  that  Jacobson  moved  it  still  further  back  into  the  sclera.  He, 
however,  abandoned  the  linear  incision,  and  made  a  Ha]i  incision  and  the 
iridectomie. 

(iraefe  made  his  opening  in  the  capsule  with  the  cystitome.  others 
with  a  discission  needle  or  a  small,  sharp  hook.  A  decided  improvement 
has  been  the  introduction  of  the  capsular  forceps.  By  means  of  this  in- 
strument, not  only  is  the  capsule  opened,  but  a  piece  of  the  anterior  cap- 
sule is  withdrawn  from  the  eye.  This  prevents  a  rapid  closure  of  the  cap- 
sule and  permits  of  a  greater  resorption  of  retained  lens  substance.  This 
procedure  has  lessened  the  number  of  secondary  cataracts.  It  has.  how- 
ever, one  objectionable  feature;  namely,  it  is  possible,  in  tearing  the  capsule, 
that  the  rent  will  be  too  extensive,  extend  too  far  into  the  equatorial 
region,  even  into  the  posterior  capsule,  and  thus  produce  conditions  favor- 
able to  prolapse  of  the  vitreous. 

During  the  sitting  of  the  Seventh  International  Optlialmological  C'on- 
gress,  held  at  Heidelberg,  in  1888,  Schweigger  wrote  the  following  sen- 
tence on  the  blackboard:  "The  bad  results  are  not  dependent  on  the  posi- 
tion or  the  size  of  the  incision."  Since  the  application  of  antiseptic  and 
aseptic  methods  to  eye  surgery,  most  of  the  complications  occurring  subse- 
quent to  a  cataract  extraction  have  ceased  to  exist;  namely,  the  wdiole  train 
of  diseases  due  to  septic  infection.  It  seems  rather  a  sad  commentary  that 
all  the  efforts  of  Yon  Graefe  and  his  school  should  have  passed  away  and 
have  been  set  aside.  Still,  to  him  remains  the  credit  of  having  greatly  re- 
duced the  ])ercentage  of  losses  in  the  pre-antiseptic  days. 

In  considering  the  changes  which  the  lens  undergoes  during  an  ex- 
traction, we  must  differentiate  between  those  of  the  capsule,  of  the  intra- 
capsular cells,  and  of  the  true  lens  substance.    The  size  of  the  wound  in  the 


3IO 

capsule  has  but  an  indirect  influence  on  the  process  of  healing.  This  mem- 
brane, aside  from  rolling  and  folding  itself  up,  remains  perfectly  indifferent 
to  the  changes  in  its  vicinity.  The  intracapsular  cells,  the  so-called  single 
layers  of  epithelial  cells  which  line  the  inner  surface  of  the  anterior  cap- 
sule, as  also  the  cellular  structures  along  the  equator,  on  opening  of  the 
capsule  and  extrusion  of  the  lens,  are  disturbed  in  their  regular  continuity 
and  brought  in  contact  with  a  heretofore  foreign  fluid.  The  manner  in 
which  they  react  has  already  been  considered  under  "Secondary  Cataract" 
and  the  "Crystalline  Pearl.'' 

Only  exceptionally  is  the  lens  removed  in  its  entirety.  As  to  what 
will  remain  in  the  capsule  depends  largely  on  the  consistence  of  the  cataract. 
Everything  of  which  the  lens  is  made  up  may  be  found — normal  lens  fibres, 
whole  or  broken  cataractous  lens  fibres,  myelin  globviles,  fat,  cholestearine 
crystals,  and  lime  salts;  all  of  which  are  incapable  of  further  development, 
hence  they  act  as  a  foreign  body.  As  we  have  seen,  the  lens  fibres*  possess 
the  peculiar  quality  of  swelling  up  to  an  enormous  size,  so  that  their  pres- 
ence may  greatly  endanger  the  further  existence  of  the  eye.  Aside  from 
this,  not  infrequently  after  an  operation,  this  capsular  epithelium  begins 
to  undergo  a  hyperplasia,  and  then  take  an  active  part  in  the  formation  of 
the  secondary  cataract  and  the  crystalline  pearl. 

If  the  extraction  is  made  so  as  to  remove  the  lens  in  its  capsule  from 
the  eye,  as  Sharp  and  Mohrenheim  attempted  to  do,  and  as  Pagenstecher 
did,  the  injury  will  be  of  a  different  character.  The  lens  (like  an  amputated 
member  of  the  eye)  can  no  longer  enter  into  the  .onsideration  of  the  pro- 
cesses of  healing;  one  must,  however,  not  forget,  that  the  lens  could  not 
have  escaped  from  the  eye  without  tearing  every  single  fibre  of  the  zonula 
zinii.  This  operation  has  been  practiced  by  Beer,  Eichter,  Sperino  Mac- 
namara  and  Andrews.  (Tiber  Staar  Extractionen  mit  und  ohne  Entfernung 
der  Kapsel  von  Herman  Pagenstecher,  Graefe,  Arch.,  Vol.  "XXXIV.,  B.  2, 
1888). 

After  completing  the  corneal  incision,  owing  to  the  evacuation  of  the 
aqueous  and  the  loss  of  the  greater  portion  of  the  contents  of  the  capsule, 
or  of  the  lens,  together  with  its  capsule,  the  globe  loses  from  2t  to  14  of  its 
volume.  Notwithstanding  this,  as  a  rule  the  eye  does  not  become  lessened 
in  size,  nor  does  it  collapse.  By  what  means  is  tliis  prevented?  It  is  evi- 
dent that,  whereas  in  the  beginning,  aqueous,  iris,  lens,  and  vitreous  fill 
out  the  space,  after  the  operation,  this  same  space  is  simply  occupied  by  iris 
and  vitreous,  where  formerly  was  aqueous  and  lens.  The  change  of  posi- 
tion to  which  these  parts  must  be  subjected,  must  be  considerable.  The 
ins  moves  forward  the  depth  of  the  anterior  chamber,  equal  to  a  distance 
of  three-quarters  of  a  uim.     'I'lie  fossa  patellaris,  which  is  still  separated 


3" 
from  the  anterior  chamber  by  the  posterior  capsule,  moves  forward  J  mm. 
Such  a  great  transposition  of  the  individual  structures  can  not  possibly 
take  place  without  materially  drawing  on  the  structural  elements  of  the  iris 
and  corpus,  ciliare,  and,  more  especially,  on  the  nerves  which  traverse  them. 
But  it  is  impossible  for  the  vitreous  to  move  forward  without  the  space 
which  it  vacates  becoming  filled  in  some  other  way. 

In  eyes  in  which  the  coats  are  still  elastic,  these  will  contract  and  re- 
duce the  volume  to  a  degree  equal  to  the  previous  tension  of  the  globe.  By 
this  means,  the  most  essential  portion  is  compensated  for.  Hence  it  follows 
that  where  the  sclera  has  lost  its  elasticity,  the  cornea  becomes  wrinkled; 
or,  owing  to  atmospheric  pressure,  is  pressed,  funnel-like,  inward. 

This,  however,  is  not  the  only  compensation.  When  the  aqueous  is 
evacuated,  and,  still  more  so,  on  evacuation  of  the  lens,  the  pressure  of  the 
blood  vessels  in  the  eye  must  be  reduced,  to  a  degree  propoi-tionate  to  that 
which  they  were  under  before  the  above  parts  were  pressed  out,  and  de- 
pendent on  the  tension  of  the  eye  itself.  Hence,  just  at  this  moment  there 
must  take  place  a  sudden  and  great  dilation  of  all  the  blood  vessels  in  the 
eye.  It  has  been  a  well-known  fact  for  a  long  time,  that  in  cases  in  which 
there  existed  a  pathological  increase  of  intra-ocular  pressure,  the  sudden 
reduction  of  this  pressure,  on  opening  the  anterioi  cliaiiiber,  has  not  infre- 
quently led  to  the  occurrence  of  hemorrhages  into  the  interior  of  the  eye. 
In  a  case,  in  which  I  (Becker)  punctured  the  anterior  chamber  for  an  em- 
bolus of  the  arteria  retinae  centralis,  with  the  hope  of  thereby  causing  the 
embolus  to  change  its  position,  I  observed  the  occurrence  of  innumerable 
retinal  ecchymoses,  though  the  intra-ocular  pressure  had  previously  not 
been  increased.  Hence  there  appears  to  be  no  doubt,  but  that  retinal 
hemorrhages  may  occur  when  an  extraction  is  made 

From  opthalmoscopic  examination,  we  know  that  where  the  intra- 
ocular })ressure  is  reduced,  on  the  use  of  atropine,  hypei-aemia  of  the  retina 
and  choroid  does  take  place,  together  with  a  dilation  of  the  blood  vessels. 
In  favorable  cases,  one  may  observe  this  hyperaemia  with  the  naked  eye, 
by  simply  watching  the  change  in  color  w^hich  a  slightly  pigmented  iris 
assumes  during  an  extraction.  Finally,  IwanofE's  experiments  have  proven 
it  to  be  not  at  all  improbable  that  even  in  cases  o-f  normal  extraction,  prob- 
ably during  the  same,  a  detachment  of  the  vitreous  takes  place,  so  that  when 
the  vitreous  moves  forward  a  vacuum  is  produced  at  the  posterior  pole,  if 
this  is  not  prevented  by  an  instantaneous  transudation.  That  which  has 
so  far  been  described,  can  and  must  occur  when  an  extraction  is  made, 
even  though  an  eye  speculum  is  not  used,  non-fixation  of  the  eye  practiced, 
when  a  lens  is  removed,  and  no  special  maneuvers  are  required  to  bring  this 
about. 


312 

Thougli  the  greatest  care  is  exercised  in  inserting  and  removing  the 
specuhini,  we  do  not  always  succeed  in  avoiding  injury  of  the  cornea.  If 
attention  were  only  directed  to  this  point,  frequently  after  cataract  extrac- 
tion, extensive  loss  of  epithelium  would  be  found.  Owing  to  the  great  im- 
portance which  such  epithelial  losses  assume,  where  infectuous  conjunctival 
secretion  is  present,  it  certainly  ought  to  receive  the  most  serious  attention. 

The  iris  may  be  involved  in  a  variety  of  ways.  In  every  case,  the 
moment  the  aqueous  is  evacuated  it  contracts  spasmodically,  so  that  where 
the  pupil  is  forcibly  distended  by  the  passage  of  the  cataract,  it  must  suffer 
a  ven'  considerable  bruising  and  transposition,  and  not  infrequently  we  find 
iris  pigment  adherent  to  the  extracted  cataract.  Even  where  the  operation 
proceeds  in  a  perfectly  normal  manner,  the  iris  is  easily  pressed  into  the 
wound,  and  then  either  draws  itself  back  by  means  of  contraction  of  the 
sphincter,  or  the  sphincter  must  be  irritated  to  contract  by  means  of 
rubbing  the  lids;  or,  finally,  the  iris  must  be  returned  to  its  normal  posi- 
tion by  means  of  instruments. 

It  is  entirely  irrelevant  whether  or  not  we  grasp  the  conjunctiva  bulbi 
alone  or  together  with  the  tendon  of  the  rectus  inferior,  in  order  to  fix  the 
eye.  Notwithstanding  this,  not  seldom  a  demonstratable  injury  is  pro- 
duced. Even  where  the  fixation  forceps  are  used  with  the  greatest  care, 
for  days  afterward,  the  points  where  they  grasp  the  conjunctiva  are  mark- 
ed by  a  suffusion.  If  the  teeth  of  tlie  forceps  are  vei-y  sharp,  and  the  con- 
junctiva (as  it  frequently  is  in  old  people)  friable,  this  will  lead  to  hemor- 
rhage, and  even  to  tearing  of  the  tissues.  Later  on,  it  will  be  shown  how 
the  sudden  occurrence  of  ciliary  injection  on  fixation  may  be  utilized  in 
determining,  whether  one  should  risk  or  put  off  the  extraction  in  a  case 
in  which  cyclitis  had  supervened  after  traumatic  cataract.  In  such  cases, 
the  simple  fixation,  in  eyes  which  were  previously  pale,  is  sufficient  to  bring 
on  ciliary  injection,  and  proves  that  this  grasping  of  the  conjunctiva  with 
the  forceps,  is  not  such  an  innocent  pi'ocedure  as  one  is  wont  to  suppose. 
(S.  Liebreieh,  1219). 

Tliat  which  has  just  been  said  bt'i-ouies  of  tncn  jiroater  importance  Avhen 
the  lixation  is  contiuuod  after  tlie  eyeball  has  been  opened,  and  even  more  so 
when  tlie  opei-ator.  after  making  tlie  (.-orneal  incision,  iu  order  to  be  able  to  ex- 
cise the  iris,  leaves  the  fixation  forceps  in  charge  of  his  assistants,  and  later 
again  takes  charge  of  them.  Since  the  eye  involuntarily  rolls  upward,  a  certain 
amoiint  of  force  must  necessarily  be  exerted  in  order  to  bring  the  wound  into 
an  accessible  position.  Even  in  the  hands  of  the  most  expert  operators  the  tension 
between  the  point  of  fixation  and  the  corneal  wound  is  undoubtedly  greater 
wheie  the  closed  forceps  hanging  to  the  eye  is  handed  over  to  an  assistant.  In 
such  cases  the  cornea  will  gap  wide  open,  and  even  fold  itself  vertically.  Just 
such  traction  on  the  cornea,  the  corpus  ciliare  and  iris  becomes  the  most  detri- 


3>3 
iiU'Ufal  factor  of  an  cxlraction.  I  »»'iicii(liii;;  on  tlic  dciiicc  to  wliicli  this  second 
pernicious  occurrence  is  avoided  will  he  found  the  secret  of  tlie  j^reat  differences 
in  the  results  of  the  various  skilled  operators.  Every  method  and  «'very  sup- 
j^estion  which  will  aid  us  in  lessening  this  portion  of  the  operative  procedure 
is  deservins:  of  the  most  earnest  eonsideration.  Hence,  one  should  «-hoose  a 
pair  of  forceps  which  are  not  too  sharp,  rather.  <lo  not  clamp  at  all.  or  can  be 
opened  every  few  moments.  One  should  not  transfer  Iheni  closed  from  one 
hand  to  the  other,  but  rather  fix  them  anew,  or  if  it  is  possible,  complete  the 
operation  after  the  corneal  incision  without  fixation.  This  becomes  easier 
where  the  operation  is  made  without  an  iridectomie.  or  where  this  has  been 
made  in  advance  of  the  extraction. 

These  sugrgestions  were  made  before  the  introduction  of  cocaine,  since  which 
time  the  operation  has  become  a  painless  one.  and  the  jtanent  can  sreatly  assist 
the  operator  by  carryinjr  out  his  orders.  Many  operators  do  not  fix  tlie  eye  at 
all  during  the  iridectomie.  but  simply  tell  the  patient  to  look  down.  Probably 
the  only  twitch  of  pain  occurs  at  the  moment  the  seetion  of  iris  is  beinj;  excised. 

All  pressure  on  the  globe,  or  displacement  of  same  by  means  of  the 
lids  or  instruments,  which  has  as  its  object  the  removal  of  the  lens  or  its 
remains,  is  to  be  looked  uiioii  as  a  part  of  the  general  injury.  Koth  may 
become  necessary  in  ]icrfectly  normal  operations.  Aside  from  the  creasing 
of  the  cornea,  and  the  |)usliing  apart  of  tlic  edges  of  the  wound,  the  corpus 
rih'are  mnst  necessarily  suffer. 

Finally,  the  introduction  of  air  into  the  anterior  chamber  or  the  escape 
of  blood  may  complicate  and  influence  the  processes  of  healing,  even  where 
the  entire  operation  was  otherwise  normally  completed.  Beer  put  partic- 
ular weight  on  the  first-mentioned  condition,  whereas  under  normal  condi- 
tions both  blood  and  air  are  rapidly  absorbed.  Nevertheless,  such  occur- 
rences always  call  forth  a  special  amount  of  resistance  to  injury  in  such  an 
eye  immediately  after  the  operation. 

Cataract  extraction  is  not  always  made  without  the  occurrence  of  so- 
called  nnlucky  accidents.  These  necessarily  must  exert  an  influence  on  the 
healing  process. 

I.  Aside  from  an  iiifdiiui.  tlic  rdnienl  iroinnl  may  be  too  largi'  or  loo 
small.  An  incision  which  is  too  large  when  the  flap  extraction  is  practiced 
either  removes  more  than  half  of  the  base,  or  at  some  point  approaches  too 
closely  to  the  ciliary  body,  if  it  does  not  strike  it  either  in  the  middle  of  the 
incision,  or  at  the  point  of  exit.  In  the  latter  cases,  a  cyclitis  is  the  un- 
avoidable consequence.  The  incision  can  only  t)e  too  small,  relatively 
speaking,  as  compared  with  the  size  of  the  cataract.  In  consequence,  the 
removal  of  the  cataract  is  made  more  difficult,  and  in  fact  can  not  be  re- 
moved without  bruising  ver\-  materially  the  edges  of  the  wound.  In  these 
cases  an  unnecessary  amount  of  cataractous  substance  retnains  behind  and 
can  only  be  removed  by  resorting  to  all  kinds  of  maneuvers.     In  order  to 


314 

deliver  the  lens,  it  is  necessary  to  employ  a  high  degree  of  pressure,  and 

hence  the  danger  of  prolapse  of  the  vitreous  is  correspondingly  increased. 

II.  A  PROLAPSUS  IRIDIS,  occurring  during  a  flap  operation,  may 
hr  cut  ofV.  and  thus  the  formation  of  a  staphyloma  averted.  But  it  is  not 
always  possible  to  prevent  the  iris  from  cicatrizing  in  the  wound  in  any  form 
of  extraction.  Even  where,  at  the  close  of  an  operation,  the  iris  is  left  in  its 
normal  position,  it  may,  later  on,  where  the  wound  opens  again  and  the 
aqueous  is  evacuated,  he  washed  from  its  position  into  the  wound  and  be- 
come fixed  there. 

III.  INCARCERATION  OF  A  TAG  OF  THE  CAPSULE.  A  tag  of 
the  capsule  may  be  dragged  into  the  wound  by  the  cystotome,  iris  forceps, 
or  at  the  time  the  lens  is  delivered.  This,  owing  to  its  transparency,  is  apt 
to  be  overlooked,  and  subsequently  be  the  starting  point  of  a  series  of 
troubles.  It  may  give  rise  to  cystoid  cicatrization,  and,  as  Wagenman  has 
shown,  to  microscopical  fistulous  openings,  which  can  give  entrance  to 
micro-organisms  and  the  whole  trains  of  symptoms  which  these  produce, 
even  to  sympathetic  opthalmia.  These  cystoid  cicatrices  lead  to  irregu- 
larities of  the  corneal  curvature  and  consequent  irregular  astygmatism. 

Where  simply  the  iris  is  incarcerated,  the  pupil  will  gradually  be 
drawn  to  tlie  upper  sclero-corneo  margin:  whereas,  if  the  capsule  is  in- 
volved, irido-cyclitis  may  be  produced.  Even  glaucoma  may  supervene,  as 
a  result  of  closure  of  the  filtrating  angle. 

IV.  It  is  not  always  possible  to  completely  remove  all  the  visible 
remains  of  a  cataract.  From  the  earliest  times,  the  swelling  up  of  these  re- 
mains has  been  looked  upon  as  one  of  the  most  detrimental  occurrences  to 
a  normal  process  of  healing. 

Y.  THE  PROLAPSE  OF  THE  VITREOUS  is  to  be  looked  upon  as 
one  of  the  most  important  complications  of  the  operative  procedure.  This 
may  occur  before  the  extraction  of  the  lens,  at  the  same  time,  or  following 
its  removal.  The  first  can  only  occur,  if  the  operation  is  not  done  too 
roughly,  where  the  vitreous  has  become  fluid,  the  zonula  zinii  previously 
become  partially  dissolved,  and  the  lens  luxated  befDre  the  operation.  It 
may,  however,  also  be  the  result  of  a  luxation  of  the  lens,  caused  by  im- 
pro])er  use  of  the  cystotome,  and  the  exercise  of  too  much  pressure  while 
delivering  the  lens.  The  escape  of  vitreous,  together  with  the  lens,  or  fol- 
lowing its  delivery,  can  be  avoided  by  exercising  a  little  care;  or  it  is  to  be 
CiMisidered  as  a  truly  unfortunate  circumstance  wlu>re  it  follows  as  the 
result  of  a  strong  muscular  contraction  on  the  part  of  the  patient.  The 
escape  of  vitreous,  previous  to  the  delivery  of  the  lens,  since  it  necessitates 
our  going  into  the  eye  with  instruments,  is  to  be  looked  upon  ns  a  verv 
i-cvcre  complication. 


i 


315 

Ever  siuee  the  iutrodiK-tioii  of  Daviel's  method,  the  escape  of  vitreous,  as 
a  novel  occurrence  during  cataract  extraction,  has  naturally  excited  the  atten- 
tion of  operators  (it  even  occurred  to  Daviel  and  he  in<'ntioncd  iti.  and  has 
therefore,  since  that  time,  been  frequently  an<l  almost  constantly  under  dis- 
cussion. It  appears  that  poor  results  were  frefiucntly  blamed  on  this  o<-cur- 
rence,  and  thus  sought  to  be  excused.  But  the  most  renowned  operators,  such 
as  Wenzel  and  especially  Beer,  opposed  this  view.  The  latter  even  went  so  far 
as  to  declare  that  one-third  of  the  vitreous  might  be  lost  without  affecting  the 
favorable  result  of  the  case.  Even  at  the  present  time  this  question  has  not 
been  definitely  settled.  With  the  introduction  of  Graefe's  scleral  extraction, 
this  question  again  stepped  to  the  front.  Von  Graefe  in  his  various  publica- 
tions always  stated  to  how  great  a  degree  he  had  reduced  the  percentage  of 
losses  of  vitreous.  Arlt  seems  to  have  followed  the  proper  course  (III  1.  p.  277), 
in  that  he  based  his  prognosis  on  the  cause  of  the  prolapse  of  vitreous.  The 
prognosis  seems  to  be  more  favorable,  where  there  has  existed  a  previous  fluid- 
ity of  the  vitreous  or  luxation  of  the  lens,  than  where,  owing  to  a  mistake  or  an 
unfortunate  circumstance  during  the  operation,  vitreous  of  a  normal  consistence 
is  lost.  In  these  cases  it  is  more  apt  to  lie  in  the  wound,  prevent  perfect  clos- 
ure, and  since  it  extends  into  the  conjunctival  sac.  where  this  is  not  perfectly 
free  from  pathogenic  germs,  become  infected.  The  vitreous  is  one  of  the  best 
soils  known  for  the  growth  of  micro-organisms,  and  where  the  vitreous  once 
becomes  infected  the  fate  of  the  eye  is  sealed;  panopthalmitis  is  sure  to  follow, 
and  sympathetic  opthalmia  is  not  an  unheard-of  occurrence. 

VI.  As  a  rare  occurrence  during  extraction,  intra-ocidar  hemorrhages 
do  occur,  even  in  the  simple  Daviel  method.  This,  it  appears,  was  first  de- 
scribed by  Wenzel  in  1779.  Beer  states  that  he  is  acquainted  with  such 
^ases,  and  says  that  he  only  operates  such  patients  at  their  earnest  solicita- 
Tion,  and  then  only  in  the  presence  of  witnesses.  However,  it  is  not  clear 
lu>w  he  could  foretell  the  occurrence  of  such  hemorrhages.  Arlt  was  of  the 
opinion  that  this  occurrence  could  be  prevented,  if  we  would  refuse  to 
operate  an  eye,  which  showed  any  evidence  of  increased  intra-ocular  ten- 
sion, without  having  made  an  iridectomie  at  least  one  week  in  advance. 
The  cause  of  such  a  hemorrhage  might,  however,  be  ^ound  in  the  condition 
of  the  blood  vessel  ivalls. 

Becker  states  that  in  1864  he  was  a  witness  to  an  operation  which  Arlt  made 
on  an  amaurotic  eye,  in  which  he  extracted  a  calcareous  lens  which  had  fallen 
into  the  anterior  chamber.  Immediately  on  completion  of  the  corneal  incision, 
an  enormous  hemorrhage  took  place  from  the  interior  of  the  eye,  so  that  the 
blood  trickled  from  the  corneal  wound.  It  did  not  come  from  the  iris,  but  rather 
from  the  corpus  ciliare.  from  the  retina  or  choroid,  for  after  the  hemorrhage  was 
controlled,  one  could  see  a  clot  protruding  from  the  pupil.  In  the  following  few 
days,  this  hemorrhage  repeated  itself,  and  caused  the  corneal  wounds  to  reopen 
again.  The  eye,  however,  was  saved,  and  retained  its  form.  This  case  was 
a  particularly  interesting  one,  because  the  patient  had  a  very  extensive  flat 
teleangiektasie  on  the  whole  half  of  the  face.  Hence,  it  is  to  be  presumed  that 
the  blood  vessels  in  tlie  eye  were  likewise  varicose. 


3i6 

There  are  but  few  cases  reported  in  literature  iu  wliieh,  during  the  oper- 
ation or  immediately  following  it,  an  extensive  hemorrhage  took  place  from 
the  choroid,  and  thus  instantly  and  forever  destroyed  the  function  of  the  eye; 
possibly  this  is  due  to  the  fact  that  but  few  men  care  to  report  their  poor  re- 
sults. As  has,  however,  been  personally  communicated  to  me  by  a  colleague, 
and  who  by  the  way  is  a  very  busy  man,  this  does  occur.  He  operated  an  aged 
physician  for  cataract,  ■who  since  early  youtli  had  been  myopic  to  a  high  de- 
gree. Immediately  following  the  delivery  of  the  lens.  Avhich  took  place  with- 
out the  occurrence  of  any  mishap,  the  vitreous,  accompanied  by  a  dazzling  sen- 
sation and  violent  pain,  Avas  extruded  through  the  wound  as  a  globule.  The 
hyaloidea  did  not  rupture,  though  blood  did  not  escape  from  the  eye,  it  could 
be  seen  through  the  vitreous.  At  the  same  time  the  eye  became  as  hard  as 
stone,  and  the  sensation  to  light  was  instantly  abolished.  The  protruding  vitre- 
ous was  cut  off.  Phthisis  bulbi  followed  without  a  corneal  ulceration.  Even  in 
such  cases  the  cause  of  the  hcnwrrhaye  is  iiu  doiiht  dur  to  a  diseased  condition  of  the 
vessel  walls  of  the  choroid. 

Dr.  J.  A.  Spaulding  ^  reported  such  a  case,  together  with  a  very  com- 
plete literary  review  of  this  subject,  but  has  evidently  overlooked  the  above 
remarks  of  Becker,  which  appeared  almost  twenty  years  ago.  Practically, 
his  statements  agree  with  those  of  Becker.  He  states,  "In  conclusion,  it 
would  seem  that  hemorrhage  from  the  choroid  after  extraction,  and  occa- 
sionally after  iridectomie,  is  by  no  means  so  rare  a  complication  as  one 
Avould  think.  Numerous  cases  have  been  reported,  and  there  can  hardly  be 
a  doubt  that  many  remain  unpublished  in  the  dread  of  publishing  what  may 
seem  to  be  a  badly  performed  operation.  But  where  we  read  the  names  of 
the  surgeons  to  whom  the  accident  has  occurred,  it  is  plain  that  the  mis- 
fortune is  due  solely  to  a  diathesis  of  the  patient.  This  being  once  estab- 
lished, we  shall  probably  hear  in  the  future  of  many  more  interesting  cases 
of  the  sort.  The  chief  cause  is  undoubtedly  atheromatous  condition  of  the 
vessels,  and  an  abnormal  tension  of  the  eyeball  suddenly  reduced  by  the 
incision  in  the  cornea  and  the  outflow  of  aqueous.  When  it  occurs,  the 
best  treatment  is  to  raise  the  patient's  head:  to  relieve  the  pain,  and  to 
watch  the  eye  carefully,  prepared  to  perform  enucleation  at  the  soonest 
possible  moment.  Where  the  accident  has  occurred  in  one  eye.  it  is  likely 
to  occur  in  the  otlier,  and  pressure  on  the  carotids  and  ergotine  is  indi- 
cated. It  does  not  appear  that  extraction  with  iridectomy  is  more  fre- 
quently followed  by  choroidal  hemorrhage  than  simple  extraction.  The 
accident  can  not  be  foreseen,  but  may  be  looked  for  witli  increased  tension; 
also  in  the  decrepid  and  those  advanced  in  years."  In  this  same  paper  he 
reports  the  statement  of  Da  Gama  Pinto  (Keviio  dc  ({eneral  d'Opth..  1884, 
p.  97),  who  witnessed  two  such  occurrences  in  Becker's  clinic. 


4  A  case  of  Choroidal  Hemorrhage  following  Extraction.    Archives  of  Opthal- 
mology,  January,  1896,  p.  92. 


317 
Sattlei-«  has  flrawn  attention  to  llic  fact  that  the  hiv^oA  nunibcr  of 
cases  of  retro-choroidal  hemorrhage  have  been  reported  sinee  coeain  lias 
come  into  use.  He  has  attempted  to  explain  this  by  the  assumption,  that 
after  the  effect  of  the  cocaine,  which  causes  c(uitraction  of  the  vessels,  has 
worn  ofl'.  an  excessive  dilatation  follows,  wliich  in  cases  where  a  predispo- 
sition exists,  is  followed  by  rupture. 

In  a  recent  imhlication,  Salina  lilooni  ''  critically  analy/.o  all  the  views 
held  as  to  the  cause  of  this  baneful  occurrence.    In  succession  are  set  aside 
as  causes,  the  loss  of  vitreous,  separation  of  choroid  from  sclera,  predispo- 
sition to  hemorrhao;e,  sudden  reduction  of  intra-ocular  pressure  and  its 
effect  on  arterial  vessels,  arterio-sclerosis,  increase  of  arterial  blood  pressure, 
as  result  of  psychic  excitement,  vomiting,  coughing,  etc..  condition  of  pos- 
terior ciliary  arteries.     "Anatomical  examination  has  shown  that  the  hem- 
on-hage  is  always  intra-choroidal,  and  that  the  predisposing  cause  is  a  phle- 
hifis  or  peri-pJilebitis  of  the  choroidal  reins.     Depending  on  the  degree  and 
stage  of  this  inflammatory  process,  and  the  time  when  the  intra-vascular 
pressure  occurs,  it  is  evident  why  this  deplorable  disaster  may  take  place 
in  persons  apparently  healthy — may  occur  in  one  eye  and  not  the  other." 
VII.     HEiMOEimAGES  WHICH   AEE  RESTRICTED   TO   THE 
ANTERIOR  CHAMBER  have  an  entirely  different  significance.   As  a  lule, 
they  only  occur  where  an  iridectomie  is  made  at  the  time  of  the  extraction. 
They  occur,  however,  more  seldom  than  one  would  imagine.     One  must 
rather  w^onder,  that  on  making  such  an  extensive  wound  in  the  iris,  that 
there  is  not  always  sufficient  blood  lost  to  make  it  perceptible  to  the  naked 
eye. 

The  causes  here  are  tlie  same  as  where  a  siiuph-  iridectomie  is  made.  Just 
as  we  observe  that  there,  where  the  instantaneous  contraction  of  tlie  blood  ves- 
sels at  the  surface  of  a  wound  j)revents  a  large  escape  of  blood,  likewise  here, 
if  the  iris  is  healthy  and  moves  so  far  forward  as  to  touch  the  posterior  surface 
of  the  cornea.  But  if  the  globe  has  suffered  in  its  elasticity,  so  that  a  reduction 
of  pressure  exists  in  the  anterior  chamber,  this  may  become  filled  with  air  or 
blood.  As  a  rule  the  blood  comes  from  the  Vessels  of  the  iris.  But  the  simul- 
taneous presence  of  air  would  lead  one  to  believe  tliat  the  blood  had  been  aspi- 
rated from  the  conjunctiva,  and  is  derived  from  the  conjunctival  vessels  cut 
during  the  operation.  Such  a  hemorrhage  may  greatly  increase  the  difficulties 
of  the  completion  of  the  extraction,  because  one  is  not  always  successful  in  re- 
moving the  blood.  The  operator  finds  himself  necessi.tated  to  open  the  capsule 
and  deliver  tlie  lens,  so  to  say.  in  th«>  dark.  The  presen<-e  of  blood  in  the  an- 
terior chamber  does  not.  however.  i)rcjudicc  tlie  prognosis  for  the  worse. 


a  Beriche  uber  die  2.1th  Versamulung  der  Opthalmogischen  Congress  in  Hei- 
delberg. 1896.  p.  211. 

b  rbcr  die  Itctro-clioioidcalblunuig  iiacli  Staar  extraction.  CJraef  Arch..  Vol. 
XLVI.  Part.  I.  p.  1S4.     1898. 


3i8 

The  same  may  be  said  of  the  presence  of  air  bubbles  in  the  anterior  cham- 
ber. Only  theoretical  considerations  could  have  lead  so  experienced  a  practi- 
tioner as  Beer  to  take  the  position  that  the  mere  contact  of  the  iris  with  air  is 
to  be  looked  upon  as  dangerous. 

Finally,  one  must  draw  attention  to  the  influence  which  is  exerted  on  the 
entire  surgical  procedure  by  the  insertion  of  instruments  into  the  eye.  especially 
such  as  are  used  for  pulling  or  exerting  tension. 

Since  the  use  of  sterile  instruments  the  fears  which  formerly  existed 
in  the  minds  of  even  the  best  operators,  regarding  the  evil  effects  of  the 
introduction  of  instruments  into  the  interior  of  the  eye,  such  as  the  mere 
entrance  of  a  cataract  knife,  the  use  of  the  cystotome  or  the  entrance  of 
the  iris  forceps,  are  of  but  historical  interest. 

It  is  interesting  to  note,  however,  that  in  the  sixties  Luer  (the  instrument 
maker)  advised  that  a  cataract  knife  should  never  be  used  immediately  after 
testing  it  on  the  drum  leather.  He  believed  that  some  deleterious  matter  con- 
tained in  the  alum  tanned  leather  might  cling  to  the  knife,  and  thus  be  brought 
into  the  eye. 

Attention  was  also  drawn  to  fine  threads  of  linen  which  might  be  carried 
into  the  eye  by  the  iris  forceps  or  cystitome.  Hence,  all  instruments  should  be 
held  up  to  the  light  and  carefully  examined  before  using  them,  to  see  that  no 
linen  threads  derived  from  the  cloth  on  which  the  instruments  are  wiped,  are 
not  still  adherent. 

The  dangers  are  greatly  increased  where  one  is  necessitated  to  deliver  the 
lens,  by  getting  in  behind  it  with  some  variety  of  spoon,  Weber's  loop  or  hook 
(Pagenstecher).  It  is  more  apt  to  occur,  since  where  it  is  indicated  there  is 
already  a  prolapsus  corporis  ritrei,  and  it  is  impossible  to  avoid  destruction  of 
the  vitreous,  bruizing  of  the  iris,  and  rough  contact  with  the  posterior  surface 
of  the  cornea.  If  by  simply  using  the  cystotome  or  iris  forceps  Ave  are  apt  to 
produce  a  traumatic  irritation  of  the  endothelium  of  the  descemetis,  how  much 
greater  must  be  this  injury  where  the  lens  is  pressed  against  the  descemetis 
by  a  constant  pressure  from  behind  the  lens. 

Irrigation  of  the  anterior  chamber,  or  intra-capsular  injection,  is  a 
method  which  has  been  practiced  by  various  operators.  -But  it  does  not 
appear  to  be  entirely  free  from  danger.  In  an  exceedingly  interesting 
paper  on  this  subject  Dr.  Hugo  Magnus  ^  gives  us  a  complete  historical 
review  of  this  subject.  He  tells  us  that  the  ancients  considered  the  aque- 
ous as  the  only  nutritive  fluid  of  the  eye  that  once  lost  it  could  not  be 
renewed,  and  that  its  loss  was  followed  by  blindness.  This  theory  was  in 
vogue  until  the  seventeenth  century,  when  it  was  refuted  by  Haller,^  who 
reviewed  all  the  ancient  history.  St.  Yves  was  the  first  to  practice  irriga- 
tion.    It  was  not  only  used  after  cataract  extraction  to  remove  cortical  re- 


5  Zur   Historischen   Kentniss   der   Voder   Kammer   Auswashungen.     Graef 
Arch.,  XXXIV,  Vol.  2,  1888. 

6  Elementa  Physiologiae  Corporis  Hunmni.    Lausanne.  1763,  Tom.  V. 


3'9 
mains,  l)ut  to  remove  intlMiiimatury  produets  in  the  anterior  cliamher.  ;m(l 
also  to  press  the  cornea  back  into  shape,  and  give  it  its  former  curvature 
after  it  had  collapsed  subsequent  to  an  extraction.  Its  application  to 
cataract  dates  back  to  the  latter  part  of  the  eighteenth  century.  In  the 
beginning  an  ordinary  syringe  was  used,  and  a  stream  of  water  forced  into 
the  anterior  chamber.  Florenze  was  the  first  to  attemi)t  to  impiove  tliis 
method.^  He  used  an  Anel's  Syringe.  Mannoir  and  St.  Yves  simply  put 
luke-warm  water  in  the  conjunctiva,  held  the  wound  oix-ii.  and  allowed 
the  fluid  to  enter  the  anterior  chamber.  C'assamanta  tells  us  how  Feller^ 
washed  out  the  anterior  chamber  with  water  and  spiritus  after  cataract 
extraction.  Beer,  however,  who  lived  in  the  early  part  of  the  nineteenth 
century,  does  not  mention  this  method.  It  was  again  recommended  by 
B.  Benedict.^  Pauli  ^^  considers  this  procedure  "an  insult  to  the  eye,"  and 
Himly  ^^  calls  it  "poor  practice."  This  method  was  dropped  during  the 
middle  half  of  the  century,  and  has  been  totally  ignored  by  the  greatest 
authorities.  It  has,  however,  been  recommended  by  McKeown,^^  Wiecher- 
kiewiez  and  Pannas.^^  Pannas  claims  that  "strict  aseptic  practice  has  set 
the  dangers  of  this  method  aside,"  and  after  removing  all  blood,  pigment, 
capsular  shreds  and  air  from  the  anterior  chamber,  he  washes  out  the 
anterior  chamber  with  a  0.005  per  cent,  solution  of  biniodide  of  mercury. 
This  method,  however,  has  not  found  general  favor,  and  is  but  seldom 
practiced. 

Sterile  1-10.000  sublimate  solution  of  atropine  or  eserine  are  well 
borne  in  the  eye. 

THE  EESULTS  OF  CLINICAL  OBSERVATION.  Beer  laid  down 
the  rule  that  nature  alone  would  heal  simple  wounds  made  with  a  clean, 
sharp  knife  more  quickly  and  more  securely  than  with  the  assistance  of  the 
surgeon;  hence,  he  criticized  every  ingenious  effort  made  to  assist  the 
healing  of  a  corneal  wound.  All  the  surgeon  has  to  do  is  to  remove  every 
obstacle  in  the  way  of  a  normal  process  of  healing. 

7  Observations  sur  une  Cataracte,  ete.  Actes  de  la  Societe  de  Medicine  Clii- 
rurgie  et  Pliarmacie  etablie  a  Brussels.  Tom  Primier  Deuxiene  Partie,  p.  11. 
Brussels,  1799. 

8  1)0  .Metliodis  suffusioiicui  (iculoniiii  cin-aiKli  a  ("assaiiiala  el  Siiudiii  cultis. 
Lipsiae,  1782. 

9  Handbucli  der  Pralctische  Augeuheillauide.     Leipsis.  1824.    B.  4.  p.  231. 

10  I'ber  den  (Jrauen  Star,  etc.     Stuttjiart.  1S24.  i).  i:!7. 

11  Die  Kranlvbeiten  und  Missbildungen  des  Auges  und  derer  Heiliinsr.  Zweiter 
Theil,  Berlin,  1843,  p.  280. 

12  British  Medical  Journal.  January  28,  1888. 

13  Des  Denier  progres  realises  dans  operation  de  la  catarael  i)ar  cxlraeiion. 
January  5-11.  1886. 


In  all  that  has  heeii  previously  slated,  the  endeavor  has  heen  made 
to  demonstrate  that  the  extraction  does  not  consist  solely  of  a  corneal 
wound,  but  that  even  in  the  most  favorable  cases  in  which,  after  an  ex- 
traction, no  signs  of  reaction  set  in,  this  simply  goes  to  show  that  under 
certain  conditions;  absolute  cleanliness,  rest,  absence  of  light,  and  all  ex- 
ternal i)ernici()iis  influences;  even  so  complicated  an  injury  will  heal. 

Naturally,  as  long  as  the  eyes  were  kept  bandaged  for  days,  the  external 
l)heuomeua  which  are  the  result  of  the  process  of  healing  could  not  be  observed. 
Beer,  who  in  the  beginning  only  removed  the  bandage  on  the  eighth  day,  finally 
shortened  the  time  to  four  days.  After  his  time  the  old  custom  again  came  into 
u.se.  and  though  Arlt  and  Vou  (iraefe  gradually  returned  to  five  days,  and  even 
three  days,  they  both  for  a  long  time  warned  against  doing  this  earlier  than  the 
third  day.  Jacobson  was  the  first  who  had  the  courage  to  overcome  tliis  preju- 
dice, for  he  not  only  removed  the  bandage  at  the  end  of  the  first  day.  but  even 
from  tliat  time  on  did  so  every  twelve  hours,  and  by  focal  illumination  examined 
the  siu-face  of  the  wound.  As  a  result  of  his  observations  and  those  of  othei'S 
we  have  finally  gained  a  knowledge  of  those  changes  which  can  be  observed 
with  the  naked  eye.  and  which  take  place  in  cases  where  everything  jn-ogresses 
in  a  perfectly  normal  manner.  It  must,  however,  be  stated  that  Kowuian  had 
previously  very  carefidly  studied  on  the  living  all  these  cliauges.  since  In  his 
lectures  (p.  28)  Ave  find  a  true  description  of  all  those  changes  which  take  place 
during  the  healing  process  of  a  corneal  wound,  and  in  such  a  way  as  could 
only  have  been  the  result  of  personal  observation.  True,  ample  opportunity  is 
given  to  study  all  these  processes,  in  cases  of  discission,  paracentesis  of  the 
anterior  chamber  and  simple  iridectomies,  and  cases  of  non-complicated  punc- 
tured and  incised  wounds. 

a.  If  we  examine  a  punctured  wound  of  the  cornea  a  few  minute>i 
after  a  discission,  it  will  appear  as  a  sharply-defined,  grey  round  spot.  In 
the  course  of  a  few  hours  this  saturated  round  spot  is  less  sharply  defined 
externally,  and  gradually  becomes  fainter,  and  is  lost  in  the  surrounding 
tissue,  usually  about  1-1^  mm.  from  the  periphery.  If  the  wound  is  aseptic, 
no  more  violent  reaction  follows,  and  in  the  course  of  a  few  days  all  that 
will  remain  will  be  a  grey  spot  marking  the  point  of  puncture.  Its  diam- 
eter will  always  be  equal  to  about  twice  the  diameter  of  the  instrument 
used,  and  can  often  be  found  unchanged  years  afterward,  by  focal  illumi- 
nation. 

h.  AVhere  a  .simple  iridectomie  or  a  simple  linear  extraction  is  made, 
the  edges  of  the  wound  will  become  agglutinated  more  quickly,  the  more 
the  line  of  incision  falls  in  the  radii  of  the  circle  of  the  corucal  surface. 
The  anterior  chamber  may  be  restored  before  sufficient  tinu'  has  elapsed 
to  apply  a  dressing.  In  such  a  case,  a  grey  line  mai-ks  the  site  of  the 
Avound,  and  by  the  time  of  the  evening  visit  thie  will  be  fouiul  to  have 
become  wider.  Where  no  infection  takes  place  the  reactiiui  will  be  ex- 
tremely slight,  oi-  the  viVj^v^.  of  the  wound  may  swell  u]i  slightly.     In  more 


321 

severe  cases  a  guttfr-like  depression  may  devcloi..  tin-  nunk'  of  licalinjr  o£ 
which  will  be  presently  described. 

c.  The  condition  of  flap  wounds  located  in  the  cornea  has  been  ex- 
perimentally studied  by  E.  Neese.^^  He  states  tliat  it  was  immaterial 
whether  a  Graefe's  knife  or  a  Beer's  knife  was  used.  Jn  his  examination, 
made  on  rabbits,  he  found  duriii<i  the  first  hour  after  the  incision  the 
epithelium  sharply  defined  and  the  cut  edges  gaping:  by  the  fourth  hour, 
the  epithehnm  in  its  entirety  has  surrounded  both  edges  of  the  wound;  by 
the  tenth  hour,  the  epithelium  is  found  descending  the  edges  of  the  wound, 
and  by  the  twelfth  hour  it  has  descended  half  way;  by  the  fifteenth  hour, 
the  epithelium  from  tlie  two  sides  has  come  together,  forming  a  sort  of 
bridge,  and  epithelial  pearls  begin  to  develop  in  the  depth  of  the  wound. 
Duiing  the  next  twenty-four  hours  the  depth  of  the  wound  fills  up  with 
epithelial  cells,  which  gradually  reach  the  surface. 

Following  an  incision   the   various  corneal   lamellae   contract,   those 
only  toward  the  center  coming  in  close  apposition,  so  that  two  triangle? 
are  formed,  with  their  apices  in  apposition.    As  is  well  known,  in  making 
the  incision,  the  plane  of  the  same  is  changed,  it  forming  either  a  curve 
or  an  angle,  and  the  depth  to  which  the  epithelium  will  descend  will  de- 
pend on  the  height  at  which  the  plane  of  incision  is  changed.    (Even  a 
more  complicated   condition   develops   where  the   modified   Graefe   linear 
extraction  is  made.)     Where  the  wound  gaps  wide  open,  the  interspace  is 
first  filled  with  transudated  fluid  from  the  corneal  lamellae,  and  exudate 
from  the  aqueous  and  iris,  until  finally  a  coagulated  fluid  closes  the  gap 
into  which  the  cells  begin  to  dip  from  above,  and  the  processes  of  resti- 
tution follow.     Active  kaiyokinetic  processes  set  in,  in  the  epithelium,  as 
far  back  as  the  limbus,  and  during  the  first  hour  the  cells  close  to  the 
margin  of  the  w^ound  are  pushed  down  into  the  wound.     After  a  time 
these  latter  cells  also  undergo  karyokinetic  changes,  and  this  process  con- 
tinues until  the  entire  wound  is  filled.     This  is  but  a  provisional  process, 
for  after  the  third  day  a  rich  supply  of  round  cells  surround  the  wound, 
and  the  real  inflammatory  reaction  does  not  follow  until  the  fourth  day, 
as  a  result  of  which  the  epithelial  indipping  is  again  pushed  out  by  the 
connective  tissue  cells.     At  this  time  the  inter-lamellar  spaces  are  widelv 
dilated,  filled  with  round  and  spindle  cells,  which  are  looked  upon  as  de- 
rivatives of  the  fixed  corneal  cells.     These  spindle  cells  become  elongated, 
assume  a  more  dense  consistence,  and  are  more  closly  packed  together. 
As  a  result  of  this  partial  fibrous  condition  and  contraction  of  the  spindle 

14  Uber  das  Verhalten  des  Epithels  bei  der  Heilung  von  Linear  und  Lanzen 
messer  wunden  in  der  Hornhaut.    Graefe  Arch.,  Vol.  XXXIII.  Bd.  1,  1887. 


322 

cells,  a  certain  degree  of  pressure  is  exerted  on  the  epithelial  indipping; 
the  lower  portion  is  simply  cut  off  and  later  on  atrophies;  the  upper  part 
is  gradually  lifted  up,  as  the  edges  of  the  wound  are  brought  closer  to- 
gether. The  upper  portion  is  raised  above  the  general  niveau,  degenerates 
and  is  cast  off.  After  three  weeks  it  is  scarcely  possible  to  follow  the 
entire  course  of  the  wound.  In  the  central  portion  there  is  an  uninter- 
rupted continuance  of  lamellae,  only  here  and  there  does  one  see  obliquely 
arranged  long  drawn  out  fibres.  Toward  the  surface,  the  membrane  desce- 
meti  is  wanting,  and  an  indipping  of  epithelium  marks  the  line  of  incision. 
Internally  the  conditions  are  relatively  the  same;  Bowman's  membrane 
does  not  close  again, 

d.  Where  there  is  a  sclero-corneal  wound,  the  conditions  are  more 
complicated,  since  we  have  here  a  wound  of  cornea,  sclera  and  conjunctiva. 
The  conjunctival  wound  soon  becomes  agglutinated,  so  that  the  sclero- 
corneal  wound  heals  under  the  conjunctival  flap.  With  perfect  asceptic 
precautions  there  is  scarcely  any  hyperaemia  or  swelling  of  the  conjunctiva, 
and  in  a  few  days  there  comes  into  view  a  blueish  scleral  cicatrix,  which, 
if  the  case  progresses  favorably,  become  paler,  until  finally  it  will  no  longer 
be  discernible  by  the  difference  in  color.    (Jacobson.) 

At  both  the  inner  and  the  outer  segment  of  Jacobson's  flap,  to  which 
no  conjunctival  flap  remains  attached,  there  at  once  follows  a  hyperaemia 
of  all  the  vessels  which  enter  the  limbus,  and  soon  this  edge  of  the  flap 
becomes  cloudy  for  a  distance  of  2-4  mm.  The  cloudiness  is  in  the  neau- 
veau  of  the  vessels,  but  lies  immediately  beneath  the  epithelium.  This  is 
to  be  looked  upon  as  the  expression  of  a  reaction,  the  result  of  a  traumatic 
''Rand  keratitis,"  which  is  necessary  in  order  to  bring  about  a  proper  heal- 
ing of  the  wound.    (Jacobson.) 

On  the  corneal  side,  one  can  always  detect  a  faint  greyish  infiltration, 
depending  on  the  degree  of  irritation  to  which  the  entire  eye  is  subjected. 
On  focal  illumination  one  can  always  discern  that  the  corneal  tissue  is 
permeated  by  greyish  white  striations,  nearly  all  of  which  are  vertically 
arranged,  extending  far  into  the  cornea.  The  width  and  the  extent  of 
these  striations  stand  in  a  relative  proportion  to  the  amount  of  reaction. 
Where  an  iritis  or  an  irido-cyclitis  complicates  the  case,  horizontal  stri- 
ations will  be  added,  and  the  extent  of  the  network  so  formed,  and  its 
density,  will  act  as  a  gauge,  by  which  we  judge  of  the  seriousness  of  the 
process.  A  cornea,  however,  which  has  become  opaque  in  this  manner 
may  again  become  totally  clear  and  transparent,  and  give  us  optically  a 
perfectly  satisfactory  result. 

This  striated  condition  of  the  cornea  subsequent  to  cataract  extrac- 
tion was  foi-mcrly  supjiosed  to  be  due  to  a  swelling  or  loosening  up  of  the 


323 

corneal  tissnc.  Ileviuan  Relieving  that  tins  was  tine  to  an  injection  of 
the  normal  lympli  channels  of  the  cornea.  Dr.  Carl  Iless,!^  as  the  result 
of  both  clinical  and  experimental  observations,  contends  that  this  appear- 
ance is  due  purely  to  mechanical  causes.  The  essential  anatomical  changes 
being  a  folding  of  the  deep  layers  of  the  cornea,  the  expression  of  which 
is  found  in  the  wavy  condition  of  the  deep  layers.  This  folding  being 
due  to  the  great  difference  in  tension  between  the  vertical  and  horizontal 
meridian,  after  the  incision,  and  in  consequence  of  which  the  cornea  is 
compressed  from  side  to  side. 

"After  the  globe  has  been  incised,  the  vertical  meridian  of  the  cornea 
becomes  very  great  as  compared  with  the  horizontal,  which  remains  almost 
?tati(  nary.  The  truth  of  this  can  be  proven  by  the  use  of  the  keratoscope. 
The  first  few  days  subsequent  to  an  operation  one  finds  the  circles  elon- 
gated vertically  to  an  astonishing  degree.  As  a  result  of  the  dift'erence 
in  the  corneal  tension  in  its  vertical  and  horizontal  meridian,  the  cornea 
is  compressed  from  side  to  side,  and  it  is  this  pressure  which  in  certain 
cases  is  sufficient  to  lead  to  the  corneal  striations,  and  accounts  for  the 
wavy  contours  of  the  deep  layers.  It  would  hardly  seem  necessary  to 
state  that  in  some  corneao  more  than  others,  there  is  some  peculiar 
condition  present,  which  acts  as  a  predisposing  cause  for  the  occurrence 
of  these  folds." 

This  striated  keratitis  should  not  be  confounded  with  the  isolated 
irregular  greyish  lines  which  give  to  the  cornea  an  appearance  very  much 
like  the  irregular  tears  and  splits  in  the  corneal  surface  observed  in  super- 
ficial keratitis  without  the  formation  of  blood  vessels.  These  markings 
are  not  observed  before  the  second  day,  and  as  a  rule  disappear  in  a  short 
time,  or  they  form  the  starting  points  for  small  ulcerations  on  the  inner 
surface  of  the  cornea.  Jacobson  believed  they  were  due  to  injuries  of  the 
inner  surface  of  the  cornea,  received  at  the  time  of  the  extraction.  Atten- 
tion is  once  more  called  to  the  erosions  of  the  epithelium  on  the  surface 
of  the  cornea,  at  the  time  of  the  operation.  It  is  also  stated  that  where 
the  bandage  has  not  been  removed  for  a  number  of  days,  and  the  wound  is 
healing  without  the  slightest  irritation,  the  epithelial  covering  along  the 
entire  extent  of  the  flap,  and  even  beyond  it.  suddenly  si^lits  up  and  is 
cast  off  in  large  shreds,  only  to  be  regenerated  in  the  course  of  a  few  days. 
An  aetiological  impetus  could  not  be  found  in  the  operation.  This  de- 
scription coincides  very  much  with   that  of  a  form  of  regular  remitting 


15  Klinische  und  Experiraentelle  Studie  uber  die  Entstehung  der  Streifen 
Hornhaut  trubung  nach  Staar  Extraction.  Graefe  Arch.,  Vol.  XXXVIII,  B.  4. 
1892. 


324 

type  of  painful  keratitis,  whicli,  tliougli  seldom  seen,  may  follow  intermit- 
tent fever,  and  this  was  even  described  by  the  ancients;  but  concerning  this 
form  modern  authorities  are  absolutely  silent.  (Becker  states  that  he  has 
never  seen  such  a  case.) 

Not  long  after  the  introduction  of  cocain,  operators  began  to  observe 
a  new  form  of,  until  then;  unknown  cloudiness  of  the  cornea,  and  especially 
after  cataract  extractions,  and  in  cases  which  showed  no  signs  of  irritation. 
This  subject  has  given  rise  to  a  great  deal  of  speculation,  investigation  and 
discussion.  Dr.  Carl  Mellinger,i6  after  reviewing  all  the  literature  on  this 
subject,  gives  us  the  results  of  his  experimental  investigations,  made  to 
determine  whether  it  is  the  cocain  or  the  sublimate  solution  which  gains 
access  to  the  corneal  tissue,  and  thus  produce  the  cloudiness.  He  con- 
cludes: 

"1.  Sublimate  solution  in  concentration  of  1-5000  causes,  where 
present  but  a  short  time  in  the  anterior  chamber,  a  passing  parenchyma- 
tous cloudiness  of  the  cornea.  But  if  present  for  a  length  of  time  a  more 
intense,  or  even  parenchymatous  cloudiness  results. 

"2.  The  cocain  alone  does  not  cause  a  corneal  cloudiness;  its  presence, 
however,  in  the  anterior  chamber  assists  in  bringing  on  the  sublimate 
cloudiness.  This  is  due  to  the  fact  that  cocaine  so  afEects  the  epithehum 
as  to  make  it  permeable  to  fluid  in  the  anterior  chamber,  and  thus  opens 
the  door  for  fluids  to  reach  the  corneal  parenchyma;  further,  it  reduces 
the  intra-ocular  tension;  it  seems  to  induce  collapse  of  the  cornea,  and 
thus  makes  easier  the  entrance  of  sublimate  fluid  which  has  remained  be- 
liind  in  the  anterior  chamber. 

3.  The  passing  sublimate  keratitis  is  due  to  the  swelling  up  of  the 
lymph  space  system  of  the  cornea.  The  endothelium  being  lost,  the  cor- 
neal tissue  takes  up  the  aqueous  and  subhmate  solution.  A  permanent 
cloudiness  follows  where  the  sublimate  comes  in  direct  contact  with  the 
corneal  parenchyma.  Practically  which  solution  is  to  take  the  place  of 
1-5000  sublimate  has  not  been  definitely  decided.  The  best  found  is  a 
3  per  cent,  boracic  acid  solution,  or  a  4  per  cent.  Na  CI  solution.  These 
have  no  effect  on  the  cornea." 

Not  infrequently  after  the  evacuation  of  the  a(|ueous.  the  cornea  is 
filled  with  creases,  vertically  arranged  to  the  direction  of  the  incision,  or 
the  center  of  the  cornea  becomes  depressed  at  the  site  of  the  pupil  and  its 
immediate  periphery,  so  that  aside  from  the  vertical  folds,  there  will  be  a 

16  Exporimentollo  I'ntorsuchungon  uber  die  Entsteluing:  der  in  letzer  zeit 
bekannt  gowordoncn  trubmiRon  der  Hornhaut  iiach  Staar  Extraction,  Graefe 
Aroh.,  Vol.  XXXVn.  B.  4,  3891. 


325 
number  of  coiK-eiitric  .un.ovcs  .>r  -ivnlcr  ..r  l(>>s  dcpili.  Tn  exaggerated 
cases  the  peak  of  tlie  (((riica  will  l)c  depivssed  fiinuel-like,  so  as  to  become 
the  deepest  point  of  llio  cdriiciil  surface,  whereas  the  periphery  is  still 
supported  bv  tlic  \r\>.  In  >ii(li  a  case,  if  the  lens  is  now  removed,  not  only 
the  entire  e(.niea,  beginning  at  the  limbus.  but  also  the  iris  sinks  back- 
ward inlo  the  fossa  patellaris. 

In  the  less  serious  cases,  the  curvature  of  the  cornea  will  be  restored  ; 
by  the  accumulation  of  tbe  a(|ue()iis.  without  any  furtlier  sequelae.  The 
formerly  depressed  place  will  still  remain  visible  for  a  few  hours,  owing 
to  the  increased  reflex.  (Jacobson.)  Whereas,  a  complete  collapse  will  leave 
for  days  a  faint  grey  cloudiness,  intersected  by  many  fun-ows,  which  will 
correspond  to  the  previous  folds.  It  is  not  at  all  an  infrequent  occur- 
rence tliat  the  cornea  will  remain  (kq)ressed  funnel-like  for  hours,  and  I 
(Becker)  have  observed  a  case  where  this  condition  persisted  throughout 
the  second  day.  The  cornea  remains  deprived  of  its  natural  glos-siness  for 
several  days,  the  cloudiness  of  its  substance  lasts  longer,  without  the  case 
taking  an  unfavorable  turn.  Subsequent  to  an  injury  with  extensive  loss 
of  vitreous,  we  not  infrequently  meet  with  this  condition;  likewise  in  cases 
in  which  prolapse  of  the  vitreous  takes  place  during  an  extraction. 

The  cause  for  this  greater  or  less  degree  of  collapse  of  the  cornea  is 
not  to  be  sought  alone,  in  the  pecuHar  condition  of  the  same.  The  fold- 
ing and  collapse  always  occur  to  a  greater  extent  where,  on  evacuation  of 
the  aqueous,  and  the  removal  of  the  lens,  the  space  thus  evacuated  is  not 
at  once  compensated  for  by  an  increased  fullness  of  the  vessels,  and  a 
moving  forward  of  the  vitreous.  But  as  has  already  been  explained,  the 
latter  can  only  occur  where  the  sclerotic,  owing  to  its  inherent  elasticity, 
is  able  to  draw  itself  together  to  a  smaller  volume,  and  the  vitreous  is  not 
obstructed  in  its  forward  movement  by  a  pathological  diaphragm,  taking 
its  origin  from  the  ciliary  body.  Hence,  the  coniea  will  always  sink  in- 
ward, when  the  sclera  has  lost  its  elasticity,  and  becomes  ^gid,  or  where 
the  vitreous  is  held  fast  by  cyclitic  bands.  If  the  cornea  is  not  supported 
from  behind,  it  is  not  able  lo  withstand  the  atmospheric  pressure.  From 
this  collapse  we  can  not  conclude  that  there  is  a  general  marasmus  of  the 
eye,  but  rather  that  the  sclera  is  rigid,  or  that  adhesions  have  formed  be- 
tween the  iris  and  the  capsule  of  the  lens,  together  with  the  formation 
of  cyclitic  bands. 

Since  the  pressure  of  the  external  muscles  of  the  eye  and  the  orbicu- 
laris act  in  the  same  sense  as  does  the  elasticity  of  the  sclera,  they  may,  to 
a  certain  extent,  replace  the  latter,  and  this  will  explain  how  tliey  facili- 
tate the  pressing  forward  of  the  vitreous,  the  moment  the  anterior  chamber 
is  opened  and  the  lens  extruded:  whereas,  when  this  factor  is  eliminated 


326 

by  chlorofonn  narcosis,  we  more  frequently  meet  with  a  collapse  of  the 
cornea.  As  has  already  been  pointed  ont,  the  same  causes  which  lead  to 
the  collapse  of  the  cornea,  also  lead  to  the  entrance  of  blood  and  air  into 
the  anterior  chamber  from  the  conjunctival  sac.  The  attempt  has  been 
made  to  explain  these  two  occurrences  by  saying  that  they  result  "ex  vacuo." 

This  wrinkling  up  and  collapse  of  the  cornea  does  not  only  occur 
after  a  flap  or  Graefe's  extraction,  but  even  after  a  simple  linear  extraction 
or  an  iridectomie.  If  one  were  to  choose  the  proper  case,  one  would  find 
that  after  a  paracentesis  the  aqueous  would  not  escape  without  the  appli- 
cation of  some  pressure  to  the  eye.  The  difficulty  experienced  in  removing 
blood  from  the  anterior  chamber  is  due  to  this  lack  of  vis  a  tergo. 

This  view  of  the  subject  is  further  supported,  as  even  Jacobson  ob- 
serves, by  the  fact  that  coUapsus  corneae,  in  all  its  various  gradations,  occur 
more  frequently  where  the  operation  is  done  under  chloroform  narcosis. 
It  is  well  known  that  an  eye  which  is  normally  distended  will  become  re- 
laxed, after  the  mere  entrance  of  the  knife  or  lance,  so  as  to  very  much 
increase  the  difficulties  of  the  operation.  Hence  I  (Becker)  do  not  entirely 
agree  with  the  views  of  Jacobson  or  Arlt. 

"Frequently  tlie  vieAV  is  met  with,  tliat  there  must  be  a  peculiar  formation 
of  the  cornea,  an  abnormal  thinness,  a  senile  marasmus  of  the  same,  which  is 
the  only  or  important  cause  of  the  coUapsns  corneae,  and  the  attempt  is  often 
made  to  explain  the  loss  of  an  eye  as  the  result  of  a  really  observed  or  sup- 
posed collapse  of  the  cornea.  They  even  went  so  far  as  to  declare  that  a  tender 
and  finely  folded  skin  on  the  hands  and  chin  would  indicate  a  similar  condition 
of  tlie  cornea,  and  owing  to  this  condition  make  a  bad  prognosis.  I  will  not 
deny  that  in  old  people  the  cornea  may  deviate  from  the  normal  and  have  a 
reduced  thickness.  Just  as  we  may  determine  the  thickness  of  the  skin  by  the 
thinness  or  thickness  of  its  creases  or  folds,  so  likewise  can  we  observe  that  the 
thickness  of  the  folds  in  the  cornea  vary,  and  hence  are  justified  in  reaching  a 
similar  conclusion,  just  as  in  respect  to  the  skin.  Becker  has  found  by  direct 
measurement  that  there  may  be  a  reduction  from  the  normal  equal  to  0.25  mm. 
In  specially  selected  cases,  which  have  for  a  long  time  been  subjected  to  in- 
creased intra-ocular  tension,  not  only  the  cornea  but  also  the  sclera  is  thinned. 
As  a  matter  of  course,  a  thin,  marasmic  cornea  would  be  less  able  to  withstand 
the  atmospheric  pressure.  Hence,  when  there  is  an  abnormal  cornea  a  collapse 
would  naturally  follow  much  easier.  In  other  cases,  where  the  surface  of  the 
cornea  has  its  normal  curvature,  we  do  see  some  cases  in  which  air  enters  the 
anterior  chamber.  Here  undoubtedly  the  extei'nal  and  internal  pressure  acting 
on  the  cornea  must  be  equal,  and  the  bubble  of  air  which  enters  the  anterior 
chamber  fills  up  the  vacuum,  and  thus  prevents  the  collapse  of  the  <'ornea.  It  is 
also  possible  for  blood  instead  of  air  to  occupy  this  space. 

"Though  I  do  not  believe  that  collapse  of  the  cornea  is  something  to  be 
wished  for,  still  I  do  believe  that  its  dangers  have  been  greatly  overrated.     It 


327 
is  not  because  the  cornea  is  niarasniic.  and  but  poorly  disposed  to  such  ac- 
tivity, as  is  required  for  the  formation  of  a  cicatrix;  tliat  tlie  collapse  of  the 
cornea  is  followed  by  such  evil  consequences,  but  oiif  imist  lather  look  upon 
these  folds  and  creases  of  tlie  individual  tissue  elements  .is  an  additional  com- 
plication of  tlie  trauma  produced  by  the  \V(mii(i.  'I'iiat  a  collapse  of  the  cornea 
may  last  for  ijuite  a  long  time  without  caiisiuij;  any  evil  results  is  attested  by 
the  fact  that  I  (Hecker)  once  observed  a  ease  in  whicli  tlie  cornea  remained 
depressed  funnel-like  for  three  days  without  the  slightest  sign  of  an  iritis,  and 
went  on  to  perfect  restitution." 

ABNORMAL  COXDITIOXS  DEVKl A ) P i: I )  1 ) IJ IM  N' ( i  'V} 1 1-:  PJtOCESS 
or  HEALING. 

Clinical  observation  teaches  us  that  the  healing  of  a  ^^clero-eorneal 
wound  may  take  an  abnormal  course  in  a  three-fold  manner,  in  that  either 
the  cicatrical  tissue  which  binds  together  the  edges  of  the  wound  gives 
way  before  the  intra-oeular  pressure,  and  in  this  manner  brings  about  the 
so-called  cystoid  cicatrix,  or  the  iris,  or  a  tag  of  the  capsule,  becomes  im- 
bedded in  the  wound,  and  is  held  fast  in  the  cicatrix. 

a.  CYSTOID  CICATRIZATION.  Whereas,  as  a  rule,  subsequent 
to  a  linear  incision  made  with  a  lance  or  Graefe's  knife,  a  narrow,  dense, 
homogenous  cicatrix  follows,  in  exceptional  cases  it  does  occur,  that  the 
apparently  reunited  edges  of  the  wound  separate  again  from  each  other, 
and  in  the  connective  tissue  which  thus  remains  loosely  connected  for  a 
long  time,  is  developed  an  ectatic  condition. 

In  the  beginning  the  process  of  healing  may  go  on  so  devoid  of  all 
irritation,  that  one  does  not  observe  the  split  in  the  wound,  through  the 
conjunctiva.  But  if  the  examination  is  made  Avith  a  magnifying  glass,  one 
mil  observe  that  though  a  number  of  dense  strands  of  connective  tissue 
do  cross  the  wound  transversely,  still  between  the  strands  one  will  see  only 
a  very  thin  transparent  membranous  substance  filling  out  the  wound.  At 
these  points,  possibly  in  a  few  days,  in  other  cases  after  a  week  or  two,  the 
wound  begins  to  give  to  the  intra-ocular  pressure.  It  occurs  at  times  that 
the  process  develops  gradually,  after  the  patient  has  been  discharged  from 
the  hospital.  The  thin,  transparent,  membranous  substance  which  closes 
up  the  interspaces  between  the  strands  is  pressed  forward;  hence,  the  situ- 
ation of  the  wound  seems  to  be  filled  up  with  a  number  of  transparent 
vesicular  prominences.  Generally  this  interstitial  substance  ruptures,  and 
in  this  manner  the  aqueous  humor  is  permitted  to  escape  beneath  the 
conjunctiva,  which  then  seems  to  be  raised  up  by  a  serous  fluid  from  the 
sclera.  This  may  take  place  many  months,  even  years  after  the  operation. 
The  above  has  been  taken  almost  verbatim  from  Graefe's  description  of 


328 

cystoid  cicatrization,  in  his  first  report  of  sequelae  of  slancoma  operations,  and 
it  is  quoted  here  because  later  on  he  declared,  that  all  that  he  had  there  said 
was  also  true  of  the  scleral  extraction. 

The  vesicular  prominences,  which  are  the  result  of  the  cystoid  cica- 
trization, may,  under  certain  conditions,  attain  the  size  of  a  pea.  The 
opening  which  forms  the  point  of  communication  hetween  the  anterior 
chamber  and  the  vesicle  is  always  very  small.  When  they  have  existed  for 
a  long  lime,  they  widen  at  their  base  so  as  to  extend  over  on  to  the  cornea 
as  well  as  into  the  episclera,  so  that  it  no  longer  can  be  looked  upon  as  an 
almost  closed  vesicle  with  a  very  tine  stem,  but  rather  as  one  situated  over 
a  wide  opening,  which  is  simply  covered  by  the  most  superficial  layers  of 
the  corneal  tissue,  which  undoubtedly  takes  its  origin  at  the  limbus.  in 
the  conjunctiva  and  episcleral  tissue. 

A  cystoid  cicatrix  does  not  occur  when  a  clean  corneal  incision  is 
made,  and  in  fact  has  only  been  known  to  occur  since  Graefe  commenced 
treating  glaucoma  by  making  the  iridectomie  incision  in  the  limbus.  Jacob- 
son  never  observed  this  occurrence  when  he  made  his  incision  for  an  ex- 
traction at  the  edge  of  the  sclera,  and  Graefe  mentioned  its  occurrence  for 
the  first  time  in  his  second  treatise  concerning  the  modified  linear  ex- 
traction. In  this  Graefe  says:  "The  injury  at  the  edge  of  the  sclera  only 
then  leads  to  cystoid  cicatrization  when  the  intra-ocular  pressure  is  in- 
creased. This  abnormal  healing  of  the  wound  has  lately  been  used  as  a 
weapon  against  this  operation,  especially  by  the  French  opponents  of  the 
Graefe  operation.    (Fano,  1259.)" 

Becker  says:  "From  my  own  experience  I  can  support  Graefe's  view, 
as  I  only  had  a  cj'stoid  cicatrix  follow  in  a  single  case,  and  in  this  case  I 
made  the  operation  when  Basedow's  disease  was  present.  All  the  other 
eases  which  are  known  to  me  are  taken  from  Arlt's  practice,  and  that  of 
my  predecessor  Knapp,  and  in  none  of  these  did  intra-ocular  tension  exist 
before  the  operation.  By  this  I  do  not  wish  to  deny  that  it  is  possible  for 
an  increased  intra-ocular  pressure  to  have  existed  and  still  have  been 
overlooked." 

"Though  Graefe  does  state,  lliat  where  cystoid  cicatrization  is  pres- 
ent, and  the  anterior  chamber  has  been  restored,  the  globe  is  always  soft, 
hence  he  assumes  that  the  aqueous  humor  must  escape  possibly  through 
the  membraiu'.  ]\Iy  cxporience  has  Ih'cu  (|uile  the  contrary,  at  least  in 
long-standing  cases,  for  I  have  always  tnuiul  the  glohe  to  he  quite  tense. 
Here  I  will  not  entirely  overlook  the  fact  that  sucli  a  cvstoid  cicatrix  may 
for  many  years  rupture  periodically." 

h.  CICATRIZATTOX  OF  TIIK  Ib'IS  1 V  TIIK  WOUND.  Very 
probably  Yon  Graefe  sei)iirated  the  cystoid  ciciiirix   fronrall  those  anoma- 


329 

loiis  changes  which  arise  in  conse.iuence  of  incarceration  of  tlic  iris  in  the 

wound. 

Just  as  in  any  iridectomies  some  of  the  iris  piuiiient  may  he  hrushed 
ofE  and  remain  in  the  wound.  Sucli  a  pigmented  cicatrix  is  frequently 
seen  after  an  iridectomie,  more  frequently  where  the  punctiire  is  made  more 
peripheric,  in  the  limbus  or  beyond  it.  The  more  peripheric  the  wound, 
the  easier  does  the  prolapse  of  the  iris  follow,  and  owing  to  the  involvement 
of  the  conjunctiva  the  channel  of  the  wound  is  deeper,  and  consequently 
pigment  is  more  easily  contained  in  the  cicatrix.  Hence,  we  can  under- 
stand how  it  happens  that,  after  an  extraction  at  the  sclero-corneal  edge, 
the  cicatrix  so  much  more  frequently  is  pigmented.  This  can  be  avoided 
where  the  wound  is  carefully  cleansed;  the  enclosure  of  pigment,  however, 
is  not  detrimental  in  any  way. 

Especially  during  the  first  few  years  after  Graefe  introduced  his  oper- 
ation, it  frequently  happened  to  him  and  to  other  operators,  that  the  iris 
prolapsed  into  the  wound,  and  became  fixed  there  during  the  process  of 
healing.  During  the  process  of  healing  one  would  then  observe  in  one  or 
both  angles  of  the  wound,  a  small  blueish-black  spot,  which  either  lay 
exactly  on  a  level  with  the  cicatrix  and  remained  there,  or  it  gradually 
became  prominent,  like  a  small  button,  and  at  times  protruded  as  a  vesicle 
of  not  inconsiderable  dimensions.  Hence,  even  in  favorable  cases,  the  pro- 
cess of  heahng  was  considerably  prolonged.  After  the  cessation  of  all 
signs  of  irritation,  we  had  before  us  a  picture  such  as  we  are  wont  to  see 
after  glaucoma  operations,  especially  where  the  operation  was  made  for 
acute  glaucoma. 

Naturally,  the  peripheric  position  of  the  incision  favored  the  prolapse 
of  the  iris;  hence,  Graefe  advised  that  the  excision  of  the  iris  should  be 
made  without  going  into  the  anterior  chamber  with  the  iris  forceps,  but 
simply  to  grasp  the  prolapsed  portion  of  the  iris,  and  where  a  ])rolapse  did 
not  occur,  this  w^as  to  be  induced  by  pressing  on  the  sclerotic  with  the 
forceps.  He  lays  down  the  rule  that,  we  should  only  cut  off  as  much  as 
has  prolapsed,  and  to  desist  from  any  effort  to  draw  the  iris  out  of  the 
wound,  and  that  that  which  does  not  easily  fall  forward  into  the  wound 
will  easily  draw  back  again,  but  for  my  part  (Becker)  T  will  admit  this 
to  hold  good  only  in  cases  where  there  is  reduced,  or  at  least  no  increased 
intra-ocular  tension.  In  such  eyes,  in  which  the  corneal  incision  is  fol- 
lowed by  a  sinking  in  of  the  cornea,  a  cicatrization  of  the  iris  in  the  wound 
never  follows.  If  the  eye  luis  a  shining,  tense  appearance  after  the  oper- 
ation, so  that  the  iris  is  pushed  against  the  posterior  surface  of  the  cornea 
with  a  certain  amount  of  force,  or  if  increased  intra-ocular  tension  was 
diagnosticated  before  the  operation,  one  may  surely  count  on  the  iris  heal- 


33° 

ing  in  the  wound,  if  one  does  not  carefully  excise  it  along  the  entire  length 
of  the  wound.  One  can  choose  but  one  alternative  in  such  a  case,  either 
to  make  a  wide  colohoma,  or  to  find  the  iris  cicatrized  in  the  wound.  Aside 
from  the  already  mentioned  prolongation  of  the  period  of  healing,  a  cicat- 
rization of  the  iris  in  the  wound,  has  the  further  injurious  effect  of  caus- 
ing not  only  a  greater  or  less  disfigurement,  hut  it  becomes  a  source  of 
continuous  irritation,  the  extent  of  which  will  l)e  proportionate  to  the 
extent  of  the  prolapse. 

Though  no  prominent  iris  vesicle  may  form,  the  simple  fixation  of 
the  iris  in  the  cicatrix  is  sufficient  to  cause  the  pupil  to  be  drawn  towai-d 
the  wound.  Further,  one  will,  from  the  contour  of  the  pupil,  where  one 
can  not  detect  both  edges  of  the  cut  sphincter  of  the  iris,  by  this  condition 
alone  determine  that  there  is  a  cicatrization  of  the  iris  in  the  wound,  even 
where  this  can  not  be  determined  externally. 

As  a  matter  of  course,  the  cicatrization  of  the  iris  in  the  wound  must 
exert  an  influence  on  the  curA^ature  of  the  neighboring  corneal  tissue,  and 
hence  influence  the  amount  of  \ision  after  such  an  operation.  Since  a 
pupil  which  is  drawn  to  the  periphery  falls  in  the  area  of  a  less  regularly 
curved  portion  of  the  cornea,  and  hence  is  less  favorably  situated  for  good 
vision,  hence,  under  all  circumstances  the  cicatrization  of  the  iris  in  the 
wound  must  be  looked  upon  as  detrimental  to  the  sight  on  the  oper- 
ated eye. 

Owing  to  the  more  peripheric  position  of  both  Jacobson's  and  Von  Graefe's 
incision,  the  almost  unavoidable  occurrence  of  an  iris  prolapse  lead  these  oper- 
ators to  make  the  excision  of  the  iris,  before  opening  the  capsule,  one  of  the 
integral  steps  of  the  operation  of  extraction.    Even  in  the  old  flap  operation,  if 
the  incision  lay  too  far  in  the  periphery,  or  even  where  only  a  part  of  it  was  so 
located,  or  where  the  globe  was  too  tense,  not  infrequently  prolapsus  iridis  fol- 
lowed.   Already  Wenzel  incised  the  iris,  starting  from  the  pupillary  edge,  where 
the  escape  of  the  cataract  through  the  pupillary  area  was  connected  with  great 
difQculty.     Maunoir  incised  the  iris  vertically  in  cases  which  he  found  it  im- 
possible to  replace  the  prolapse,  and  by  this  means  found  that  it  drew  back  of 
its  own  accord.    In  cases  in  which  the  lens  pushed  the  iris  pouch-like  before  it, 
Pourfoor  du  Petit,  and  later  Carron  de  Yillards,  excised  a  piece  of  the  iris  with 
a  scissors,  and  thus  made  an  artificial  opening  for  the  escape  of  the  lens.     The 
occasional  excision  of  the  iris  after  the  extraction  of  the  lens  was  practiced  by 
Von  Graefe  and  .Tacobson.    In  all  these  cases  the  iris  lays  itself  with  its  surface 
in  contact  with  the  wound,  so  that  the  iri.s,  like  :i   dolli.  is  plugged  into  the 
wound  from  within.     Under  certain  conditions  tlie  .Kiufous  continues  to  press 
it  more  and  more  into  the  wound,  until  finally  it   cxlciids  beyond  tlic  external 
level   of  tlic   w<)\iii(i.      It   iiijiy.   hoAvevcr.   beeonie   tixcd   :it    ;iny  point   .-ilong  the 
channel  of  tlie  wo\in<l.  :il   its  inner  opening,  .-ilong  tlie  eiiiinn.'l  of  the  woimd.  at 


331 
its  outor  opening,  or  linally  it  may  be  puslied  forward  like  a  vcsiele  liciicatli 
the  conjunctiva.  In  the  hist  case,  the  prohiimts  iridis  is  covered  externally  l)y 
the  conjunctiva.  This  tinally  is  forced  apart,  and  Ave  find  an  atrophic  iris  tissue. 
and  finally  we  have  a  diverticulum  of  tlie  aiiiciior  ctiaiiilM")-,  wiiicii  is  conuecti'd 
by  the  latter  by  a  very  minute  fistula. 

This  surface  cicatrization  is  to  be  differentiated  from  the  cicatrization  of 
the  stump  of  the  excised  portion  in  the  wound.  As  a  rule,  this  latter  condition 
can  not  be  diagnosticated  during  life.  This  form  of  cicatrization  occurs  more 
frequently  than  at  the  edges  of  the  wound.  If  during  the  operation  tlie  iris  is 
transfixed  by  the  knife,  it  may  happen  that  a  shred  of  iris  will  remain  in  the 
center  of  the  wound.  Here,  then,  one  is  given  the  opportunity  of  studying  this 
form  of  healing  of  the  iris  in  the  wound.  Aside  from  a  pronounced  pigmentation 
of  the  cicatrix,  no  other  evil  results  of  this  mode  of  cicatrization  has  as  yet 
been  noted.  However,  this  cicatrization  of  tlie  iris  may  become  the  starting 
point  of  other  pathological  changes.  It  appears  tlial  just  the  minute  degrees 
of  this  condition  are  the  frequent  cause  of  chronic  ivciining  iritis  and  irido 
cyclitis,  and  may  even  become  the  cause  of  a  sympathetic  optlialmia. 

The  cause  of  this  recurring  chronic  iritis,  irido-cyclitis  and  sympa- 
thetic opthahnia  has,  since  the  above  was  written,  been  explained  by 
Leber,!''  who  demonstrated  that  where  the  iris,  ciliary  body,  or  even  the 
capsule  of  the  lens,  cicatrized  in  the  wound,  they  gave  rise  to  slight  differ- 
ences in  the  niveau,  the  formation  of  slight  nodules,  and  the  epithelial 
covering  of  these  is  very  apt  to  be  stripped  off.  Now  should  a  microbic 
infection  take  place,  the  condition  is  produced  which  leads  to  inflamma- 
tion. This  has  been  conclusively  proven  by  the  further  investigations  of 
Wagenniann,!'^  who  has  shown  that  microbes  gain  entrance  along  fistulous 
tracts  year?  after  an  apparently  successful  operation.  Here  then  are  the 
conditions  which  lead  to  sympathetic  opthalraia,  and  no  plea  (for  great 
care  in  the  mode  of  making  the  incision,  the  strictest  care  in  the  toilet  of 
the  wound,  in  seeing  that  the  edges  are  free  of  coagula,  that  the  iris  is  free 
and  in  its  proper  position,  and  that  its  edges  where  an  iridectomie  has 
been  made  are  not  lying  in  the  wound,  that  no  shreds  of  capsule  are  lying 
in  the  wound)  could  equal  in  impressiveness  a  careful  study  of  the  above 
quoted  investigations.  They  will  elucidate  a  whole  train  of  evil  results, 
and  where  the  admonitions  are  observed  will  to  a  very  large  extent,  if  not 
absolutely,  prevent  their  occurrence.  Strirl  asepsis  during  an  operation  is 
one  thing,  hut  who  can  imtch  the  progress  of  cases  years  after  an  operation 


17  Uber  die  Intercellular  Lucken  des  vodern  Hornliant  Epithels  in  normalen 
und  Pathologischen  Zustahde.     Graefe  Arch..  XXIY.  p.  24.    1S7S. 

na  Uber  die  operationsnarben  und  vernarl)tc  iris  falle  ausgehende  glas- 
korper  eiterungen.     Graefe's  Arch..  XXY.  B.  IV,  p.  110.    1889. 


332 

atn]  prcrnil  siihsn/iieitl  iiifi'iliou.  t'spccidllii  irlicrc  Ihe  conditions  of  ihe  cicatrix 

of  the  wound  offer  on  opportnnifi/  for  infection. 

Wliert'  these  stapliylomatoii.s  vesicles  become  very  pronouuced.  it  often  be- 
comes necessary  to  excise  tlie  cyst  walls.  Tlionjih  this  procedure  may  seem  a 
very  simple  one,  it  can  not.  however,  be  uudertalien  withotit  observing  the 
very  greatest  care.  Thougli  pressure  by  means  of  a  bandage  may  be  applied 
for  a  long  time  (Von  Graefe),  the  result  is  not  certain,  in  that  frequently  at  the 
point  where  the  iris  cyst  formerly  existed,  there  develops  afterward  a  cystoid 
cicatrix.  As  stated  in  the  beginning,  as  much  as  I  agree  with  A'on  Graefe  in 
separating  the  cystoid  cicatrix  from  the  cicatrization  of  the  iris  in  the  wound, 
likewise  of  the  capsule,  it  nevertheless  does  occur  that  we  find  all  these  pro- 
cesses developing  one  next  to  the  other  in  the  same  eye.  The  iris  or  capsule,  or 
both,  which  become  fixed  in  tlie  wound,  are  the  cause,  that  adhesion  per  primam 
does  not  follow,  and  consequently  the  tissue  which  is  necessary  to  fill  up  this 
space  becomes  predisposed  "to  give,"  and  form  an  ectafde. 

Though  at  the  close  of  the  operation  the  iris  may  not  be  found  in  the 
wound,  still  it  is  possible  that  in  cases  where  the  aqueous  later  on  forces  the 
wound  open  again,  the  iris  may  later  on  be  washed  into  the  wound,  and  this  is 
more  apt  to  occur  where  there  is  inci-eased  intra-ocular  tension. 

c.  HYPEEAEMIA  OF  THE  IKIS.  Only  those  phenomena  will  be 
considered  which  can  not  he  looked  upon  as  the  results  or  complication  of 
pathological  processes  occurring  in  other  parts  of  the  eye.  The  first 
changes  in  the  iris  show  themselves  even  during  the  operation.  After  the 
evacuation  of  the  aqueous,  but  more  so  after  evacuation  of  the  lens,  the 
iris  assumes,  just  as  it  does  in  many  cases  of  iritis,  a  darker  color,  and  at 
the  same  time  a  slight  discoloration.  The  latter  changes  become  more 
apparent  when  the  iris  has  a  light  rather  than  when  it  has  a  dark  color. 
Both  conditions  are  due  to  a  violent  injection  of  the  ciliary  vessels,  which 
must  necessarily  follow  as  soon  as  the  pressure  on  the  tissue  is  removed. 
At  times  some  of  the  blood  vessels  of  the  iris  suddenly  become  visible,  or 
slight  hemorrhages  take  place  in  the  tissue,  or  in  the  anterior  chamber. 
If  no  complications  are  present  this  soon  disappears  after  restoration  of 
the  anterior  chamber. 

d.  SIMPLE  TPAr:\rAlT('  {)\\  ADlIivSn'K  Harris.  Wbere  atro- 
pine is  dropped  into  an  eye,  one  almost  invariably  finds  that  its  action  is 
entirely  abolished  at  tbo  time  of  or  dni'lng  tlu^  first  few  hours  after  an 
operation.  Only  gradually,  do  \v(>  notice,  that  it  begins  to  exert  its  influ- 
ence again,  and  even  then  not  along  the  entire  extent  of  the  old  pupil  and' 
its  coloboiiia.  Tlie  two  sides  of  the  coloboma  seem  to  offer  the  greatest 
resistance.  In  t'avoinbly  ])i-ogressing  cases,  we  notice,  on  making  our  even- 
ing visit  or  ilic  following  morning,  that  the  jnipil  and  coloboma  are  dilated 
regularly.     In  other  cases  adhesions  an-  noted.     This  can  onlv  occur  where 


333 

the  capsule  of  the  lens  and  the  ed-es  of  the  iMi|.il  l..n.l,  cm.Ii  -ith.-r.  Hence, 
the  less  complete  the  cvaciialion  of  the  lens  has  been,  and  the  longer  the 
time  elapsed  hefore  the  anterior  diaiuher  is  restored,  the  more  easily  will 
this  occur.  These  ohservations  indicat.'  tliat  l)ut  a  very  short  time  subse- 
quent to  the  operation  is  sufhcieut  foi-  an  adhesive  iiitis  to  develop  along' 
the  ed^es  of  the  wound,  in  the  new  pupil,  and  at  >in-lc  pnint>  along  the 
old,  and  this  manifests  itselt  by  the  early  adhesions  between  the  wounded 
iris  surface  and  its  closest  neighborino-  tissue  (be  this  a  .^^hred  of  the  capsule 
or  minute  intra-capsular  reiuains  or  blood  clots).    (Jacohson.) 

If  we  desire  to  prevent  seclusion  of  the  pupil,  active  u.«e  of  atropine 
is  indicated.  Such  synechia,  if  once  forjned  along  the  edges  of  the  new 
pupil,  can  not,  in  most  cases,  be  broken  up  again. 

e.  PLiVSTIC  IKITIS  is  to  he  dill'erentiated  from  the  adhesive  variety. 
This  likewise  sets  in  soon  after  the  extraction,  often  with  but  slight  sub- 
jective symptoius.  even  when  the  tlaj)  wound  has  healed  normally,  and 
characterizes  itself  in  that,  to  begin  witli.  there  is  little  clotidy  aqueous, 
yellowish  flakes  appear  in  the  pupillary  area  which  do  not  sink  to  the 
floor,  but  retain  their  original  position,  and  very  soon  form  adhesions  with 
the  edges  of  the  pupil,  and  later  on  also  f(»rm  demonstrable  attachments 
behind  the  iris.  Stich  yellowish  (le])()sits  may  develop  inside  of  twenty- 
four  hours  on  the  anterior  surface  of  the  iris,  and  in  the  aqueous  without 
the  formation  of  a  fluid  ]uis.    (Jacohson.) 

Occasionally  one  observes  a  jelly-like,  yellowish  exudate,  like  the 
spawn  of  frogs,  which  tirst  appears  l>etween  the  edges  of  the  wound,  and 
finally  gets  into  the  anterior  chamber.  It  may  accumulate  to  such  a  de- 
gree as  to  fill  out  the  entire  anterior  chamber,  at  the  same  time  showing 
such  a  slight  cloudiness  as  to  still  permit  one  to  distinguish  tho  finer  lines 
on  the  surface  of  the  iris,  so  that  one  inclines  more  to  the  belief  that  one 
is  dealing  with  a  very  faint  cloudiness  of  the  cornea,  rather  than  an  exu- 
date on  the  iris.  Only  when  this  begins  to  contract,  and  the  peripheiT  of 
the  iris  becomes  clear,  does  it  become  evident  as  to  just  what  we  are  deal- 
ing with.  This  jelly-like  mass  continues  gradually  to  contract  more  toward 
the  edges  of  the  artificial  pupil,  and  at  times  is  so  completely  resorbed 
that  aside  from  a  perfectly  transi)arent  mem1)rane  in  the  pujiil  (t-a])sidar 
thickening),  and  a  few  synechia,  nothing  remains. 

Becker  states  that  he  observed  this  form  of  ])lastic  iritis  twice  in  dia- 
betic patients,  and  in  fact  only  where  the  cataract  was  tumescent.  It  seems 
most  probable  that  the  intensely  swollen  condition  of  the  lens  is  the  main 
cause  of  the  chronic  irritation  of  the  iris  and  the  ii'itis.  ("hemosis  and 
swelling  of  the  lids  is  still  to  be  mentioned  as  occasional  occurrences,  but 
to  only  a   moderate  degree:  but  true  ciliary  ])ain   and    purulent    conjunc- 


334 

tival  secretion  are  entirely  wanting.    In  these  cases  a  true  hypopyon  never 

occurs  (when  it  does  the  diagnosis  is  infection). 

f.  After  the  original  sclero-corneal  wound  lias  closed,  after  the 
second  or  third  week,  a  form  of  iritis  may  still  develo]).  which  is  character- 
ized by  its  persistence  and  relapses.  Tp  to  this  time  the  process  of  heal- 
ing may  have  appeared,  to  be  perfectly  normal.  The  only  change  seems  to 
be,  that  the  eye  appears  injected,  and  the  iris  assumes  a  darker  color  or  a 
slight  discoloration.  Without  any  change  in  the  form  of  the  pupil,  ciliary 
injection  sets  in,  together  with  irritability  to  light,  tearing  and  pain.  It 
is  not  necessary  for  vision  to  be  reduced,  and  we  suddenly  find  a  slight 
hypopyon,  which  at  times  disappears  and  suddenly  appears  again.  If  the 
patient  lies  on  his  back,  the  hypopyon  disappears,  whereas,  as  soon  as  he 
moves  about  it  develops  again.  This  may  continue  for  days,  even  months. 
This  peculiar  fonu  has  been  observed  in  cases  in  which  the  capsule  was 
removed,  together  with  the  lens.  The  final  result  may  be  a  perfectly  good 
one. 

Owing:  to  the  fact  that  the  iris  shows  no  visible  changes,  that  the  hypopyon 
disappears  when  the  patient  lies  on  his  back  and  develops  again  when  he  moves 
about;  and  finally,  that  it  develops  even  when  the  eai*sule  is  wanting,  and  also 
owing  to  the  pain  in  the  ciliary  region,  it  is  possible  that  the  ciliary  body  is 
involved;  hence,  it  would  probably  be  more  correct  to  designate  this  form  as  a 
relapsing  irido-cyclitis.    All  therapy  seems  to  be  useless. 

The  above  description  is  undoubtedly  that  of  an  infection. 

g.  A  few  hours  after  an  operation  one  may  perceive  changes  in  the 
pupillary  area,  which  will  indicate  if  at  the  completion  of  the  procedure 
we  will  get  a  black  pupil  or  not.  Xot  infrequently  it  happens,  that  though 
at  the  close  of  the  operation  the  pupillary  area  appears  perfectly  black,  we 
are  surprised  at  our  evening  visit  to  find  the  ]uipillary  area  "filled  with  a 
considerable  amount  of  cloudy  cataractous  remains."  Though  Ihe  pupil 
appears  black  at  the  close  of  the  operation,  this  does  not  indicate  that  the 
entire  lens  has  been  removed.  If  the  examination  made  previous  to  the 
operation  proved  the  anterior  lamellae  of  the  lens  to  be  still  transparent, 
these  will  remain  adherent  to  the  capsule  at  the  time  of  the  operation,  and 
later  on  became  cloudy.  But  it  is  likewise  possible,  though  all  the  anterior 
layers  be  cloudy,  for  some  of  the  posterior  to  have  been  transparent,  and 
these  will  ivuiain  adh(>reiil  and  uuiu^ticed  after  an  extraction.  True 
we  term  as  catarada  maiura,  a  lens  system  which  has  become  completely 
cloudy,  and  this  cloudim^ss  has  extended  to  the  anterior  chamber.  Just 
as  it  is  possible  for  the  posterior  cortical  substance  to  remain  cloudy  for 
years,  in  the  so-called  choroideal  cataracl,  the  anterior  portion  reiuaining 
clear,  likewise,  it  is  possible  for  the  same  condition  to  occur  in  just  oppo- 


335 
site  form.  However,  we  do  not  as  yet  possess  the  means  of  making  a  diag- 
nosis of  such  a  condition.  This  condition  does  exist,  for  in  a  number  of 
eases  Becker  found  tlie  regular  radiating  arraugemoiit  of  the  cloudy  re- 
mains of  lens  substance  when  the  cxiiniination  was  made  at  the  evening 
visit. 

Frequently  cataraclous  remains  came  into  view,  which  at  the  time  of 
the  oi)eration  were  hidden  behind  the  iris.  After  the  wound  is  closed  and 
the  anterior  chamber  restored  they  may,  owing  to  their  tumescence,  appear 
in  the  pupillary  area,  or  where  an  iridectomie  has  been  made  in  the  area 
of  the  coloboma. 

Not  infrequently  it  is  impossible  to  get  the  pupil  entirely  clear.  Even 
in  these  cases,  on  making  the  first  visit,  the  quantity  of  cataractous  mass 
remaining  seems  increased,  undoubtedly  due  to  the  action  of  the  aqueous 
in  causing  it  to  swell  up. 

The  general  course  of  the  operation  largely  depends  on  the  amount 
of  cataractous  substance  retained.  Nevertheless,  it  is  very  difficult  to  de- 
termine jnst  how  much  cataractous  mass,  if  left  behind,  can  become  an 
element  of  danger.  Hence,  one  of  the  principal  objects  in  every  extraction 
must  always  be  to  remove  as  much  lens  substance  as  possible.  According 
to  many  operators,  the  condition  of  the  cataract  is  not  entirely  without  its 
influence.  At  times  a  certain  variety,  a  sticky  (pasty)  consisd;ence  of  the 
cortical  substance  in  cataracta  nondum  matura,  at  times  the  pasty  mass  of  an 
overripe  cataract,  is  said  to  be  especially  dangerous.  There  does  not  appear 
to  be  a  uniform  agreement  of  opinion  on  this  point.  But  as  there  is  un- 
doubtedly a  chemical  action,  taking  place  in  the  secondary  disintegration 
of  the  cataractous  mass;  hence,  a  priori  we  must  admit,  that  the  remains 
of  an  overripe  cataract  may  act  in  a  detrimental  way,  owing  to  its  chemical 
constitution. 

As  a  rule,  cataractous  remains,  even  when  present  in  considerable 
amounts,  in  and  of  themselves  do  not  cause  a  reaction  which  will  end  dis- 
astrously to  the  eye.  The  main  danger  undoubtedly  lies  in  the  fact,  that 
these  cataractous  remains  may  become  a  very  detrimental  complicating 
factor,  where  other  portions  of  the  eye  are  not  well  disposed.  In  this 
manner  the  attempt  has  been  made  to  explain  the  bad  prognosis  in  cases 
of  unripe,  especially  tumescent  cataracts.  In  these  ^ases,  even  before  the 
operation,  the  iris  is  irritated  by  llie  swollen  lens,  and  from  this,  the  active 
reaction  sets  in. 

Undoubtedly  the  most  freciuent  sequelae  of  cataractous  remains  are 
posterior  synechia.  Aside  from  these  a  cataracta  secundaria  nearly  always 
develops.  Cases  do  occur  in  which  the  ])upil  remains  free  and  totally  black, 
and  in  which  after  complete  healing,  even  on  focal  illumination,  one  can 


336 

only  detect  a  somewhat  ()])alt'seent  incmhrane.  the  posterior  capsule,  but 
they  are  exceedingly  rare.  They  can  only  l)e  exphiined  by  supposing  that 
immediately  after  an  opei-ation,'  the  edges  of  the  capsule  draw  back  far  into 
the  periphery,  so  that  only  the  posterior  capsule,  entirely  free  of  lens  sub- 
stance, remains  in  the  pupillary  area.  The  remains  of  lens  substance  left 
in  the  equatorial  region,  are  at  once  shut  oti'.  hence,  can  not  swell  up  and 
therefore  give  rise  to  no  further  troul)l('. 

//.  If  one  waits  a  certain  length  of  time  before  applying  the  bandage, 
or  if  from  any  cause  it  becomes  nec<'ssary  to  remove  it.  one  will  at  times 
note  how  very  quickly  the  anterior  chamber  is  restored.  For  this  to  occur 
the  entire  length  of  the  wound  must  become  agglutinated,  and  further,  to 
have  attained  a  certain  amount  of  security.  If  at  the  next  visit  the  con- 
dition has  remained  unchanged,  it  becomes  \''ery  probable  that  this  closure 
following  the  operation  will  remain  a  permanent  one. 

Paracentesis  of  the  anterior  chamber  has  taught  us.  that  a  very  few 
minittes  are  sufficient  to  permit  the  accumulation  of  a  requisite  amount  of 
aqueous.  If  the  anterior  chamber  is  punctured  so  as  to  evacuate  the  aque- 
ous at  regular  intervals,  so  as  to  ease  pain  in  the  eye,  it  will  be  found 
necessary  to  repeat  this  procedure  every  four  or  five  minutes. 

In  most  cases  this  closure  of  the  wound  does  not  follow  so  quickly 
'  subsequent  to  an  extraction,  or  at  least  is  not  of  a  permanent  character. 
Though  we  do  frequently  find  the  anterior  chamber  restored  on  making 
'  our  evening  visit,  still  one  may  expect  it  to  open  again  several  times  before 
it  finally  becomes  securely  closed.     Patients  state  that  after  they  have  ex- 
perienced a  slight  increase  of  tension  in  the  eye,  they  suddenly  experience 
a  stinging  pain,  following  which  the  pressure  seems  to  be  removed,  and 
■  at  the  same  time  they  experience  a  feeling  as  though  something  were  flow- 
ing out  of  tlieye.     The  aqueous  which  reaccumulates  must  reestablish  the 
intra-ocular  pressure,  and   unless  the  wound  closes  securely,  must  neces- 
sarily rupture  it  again. 

As  has  been  said,  in  exceptional  cases  the  wound  does  not  close  on 
the  first  day,  so  that  on  making  our  visit  we  still  find  the  anterior  chamber 
abolished.  I  have  seen  such  a  condition,  which  is  generally  recognized  as 
following  glaucoma  operations,  follow  a  cataract  extraction,  and  continue 
for  four  or  five  days,  and  in  cases  where  everything  seemed  to  be  pro- 
gressing in  a  perfectly  normal  manner.  .lacob.-on  rejtorted  c:\<es  in  which 
the  closure  did  not  take  place  duiing  the  first  few  weeks  (1.  c.  p.  194). 
During  this  time,  the  eye  must  not  necessarily  show  any  sign  of  reaction, 
and  the  result  without  exception  is  a  good  one.  One  must  not  imagine 
that  the  entire  surface  of  the  wound  iciuain.-  open,  hut  there  is  ])0ssibly 
a  verv  minute  point,  srmewhere.  at  which  the  aipieons  is  continually  evac- 


.^37 
vating  itself,  or  there  is  possibly  a  valve-like  closure  which  periodically 
permits  the  aqueous  to  escape.  Where  a  conjunctival  flap  has  been  made 
this  escape  of  aqueous  may  be  recooni/,..d  by  the  conjunctival  oedema. 
Where  a  purely  corneal  incision  is  made,  this  condition  is  always  entirely 
absent,  even  where  there  is  a  late  closure.  It  is  possible  for  the  anterior 
chamber  to  be  restored,  even  where  this  conjunctival  oedema  is  present. 
This  takes  place  when  the  pressure  of  the  aqueous  beneath  the  conjunctiva 
is  at  least  equal  to  iliat  of  ilie  intra-ocular  pressure.  If  in  such  a  case  one 
punctures  the  conjunctiva,  the  anterior  chamber  will  be  abolished. 

That  tlie  entire  extent  of  the  wound  does  not  remain  open  is  attested 
by  the  fact,  that  it  presents  all  those  conditions  which  have  above  been 
described  as  being  present  where  the  progress  of  the  case  is  a  normal  one. 
True  one  would  suppose  that  the  point  where  tlie  wound  has  not  closed 
would  be  indicated  by  a  circumscribed  area  of  reaction,  still  1  (Becker) 
have  never  been  able  to  find  one. 

The  cause  of  a  late  closure  may  lie  in  the  peculiar  formation  of  the 
incision,  as  where  this  is  jagged,  and  hence  but  an  incomplete  apposition 
of  the  edges  of  the  wound  follow.  More  frequently,  however,  it  will  be 
found  that  remains  of  lens  substance  or  a  shred  of  the  capsule  of  the  lens 
has  gotten  in  between  the  edges  of  the  wound,  and  is  keeping  the  two  sur- 
faces separated,  and  thus  making  it  possible  for  the  aqueous  to  escape. 
These  cases,  which  terminate  favorably,  have  nothing  in  common  with 
those  cases  in  which  a  delayed  closure  is  caused  by  an  increased  intra- 
ocular tension.  IIitc  we  would  be  dealing  with  a  very  dangerous  compli- 
cation, which  had  been  overlooked.  Such  eyes,  if  they  heal  at  all,  do  so 
only  under  the  most  dilficult  conditions.  Indeed,  one  ought  to  be  glad 
if  they  heal  at  all,  even  with  an  ectatic  cicatrix.  Here  the  same  conditions 
exist  as  they  do  in  glaucoma,  even  though  the  anterior  chamber  is  abol- 
ished, the  tension  of  the  globe  will  still  remain  increased,  vision  remains 
reduced,  and  the  result,  as  far  as  vision  is  concerned,  is  exceedingly 
doubtful. 

I  may  hero  remark,  that  so  long  as  the  aqueous  escapes  it  is  impossible 
for  an  increased  intra-ocular  tension  to  develop.  It  seems  most  probable, 
that  the  increased  tension  which  arises  as  a  result  of  operative  procedure, 
must  be  a  most  detrimental  factor  in  cases  which  do  not  progress  favorably. 
Hence,  such  an  opening  in  the  wound  may  be  looked  ui)on  as  a  regulator 
of  this  dangerous  intra-ocular  tension. 

i.  One  must  not  confound  abolition  of  the  anterior  eliamber  with 
the  condition  following  iritis  or  the  swelling  up  of  the  remains  of  lens 
substance,  which  in  the  first  few  days  following  an  operation  make  the 
anterior  chamber  verv  shallow.     Here  one  will  find   tlu>  siu'iis  of  an  iritis 


338 

or  swollen  up  remains  of  lens  substance.  The  aqueous  is  found  to  be 
especially  cloudy.  The  anterior  chamber  is  not  narrow  because  the  aque- 
ous is  being  constantly  evacuated,  but  because  the  iris  and  tbe  capsule  of 
the  lens  are  pressed  forward. 

On  tbe  other  hand,  an  unusually  dee}*  anterior  chamber  may  develop 
shortly  after  an  operation.  The  aqueous  may  remain  perfectly  clear,  the 
iris  lie  somewhat  deep  and  tremble  markedly.  Focal  illumination  will 
then  show  a  very  considerable  space  existing  between  capsule  and  iris. 
Such  eyes  heal  without  any  posterior  synechia,  and  good  vision  is  obtained. 
In  old  people,  on  whom  flap  operations  are  made  without  iridectomie,  in 
most  cases  the  pupil  is  narrow,  perfectly  round,  and  only  the  practiced  eye 
can  distinguish  the  trembling  of  the  iris,  which  lies  deeply  and  in  a  per- 
fect plane  behind  the  cornea,  and  owing  to  the  fresh,  clear  appearance  of 
the  eye,  recognize  that  he  is  not  dealing  with  a  case  of  luxation  of  the  lens, 
but  with  a  case  of  aphakia,  following  extraction. 

If  the  iris  lies  deep,  the  pupil  wide,  and  the  aqueous  from  the  beginning 
abundant  and  cloudy,  one  will  observe  movable  opacities  in  the  anterior  portion 
of  the  vitreous,  and  a  characteristic  blueish  red  peri-corneal  injection.  At  the 
same  time  the  globe  is  tense.  Jacobson  observed  this  condition  in  hydropthal- 
mic  eyes.  This  is  explained  by, the  fact  that  owing  to  the  altered  conditions  of 
intra-ocular  tension  subsequent  to  extraction,  a  profuse  exudate  follows  from 
the  dilated  vessels  of  the  distended  anterior  segment  of  the  eyeball.  Such  a 
hypersecretion  of  humor  aqueous  is  said  to  interfere  more  with  the  firm  healing 
of  a  flap  wound  than  with  the  tinal  general  result.  Puncture  of  the  anterior 
chamber  would  eveTitually  \)v  indicated  in  such  a  case. 

PROCESSES  OF  hp:aling  with  incompeete  resuets. 

Since  the  object  of  an  extraction  is  to  remove  the  interference  with 
sight,  which  is  located  in  the  cloudy  lens,  hence,  all  tinal  results  which 
interfere  with  the  perfect  attainment  of  this  end  must  be  designated  as 
incomplete  results.  We  must,  however,  differentiate  between  those  cases 
which  are  improved  by  a  second  operation  and  those  which  are  to  be  looked 
npon  as  lost,  so  far  as  sight  on  the  eye  is  concerned.  In  such  cases  the 
second  operation  is  always  made  for  secondary  cataract  (ratararfn  secun- 
daria). Such  a  cataract  may  exist  without  a  complication,  or  //  is  adherent 
io  the  iris:  hence,  at  the  same  time  a  cataracla  accreta.  A  secondary  cata- 
ract may  be  complicated  by  other  changes  which  may  occur  after  an  oper- 
ation, such  as  the  formation  of  cyclitic  bands  and  detachment  of  the  vitre- 
ous. But  since  operations  made  on  these  (•om))licated  cases,  as  a  rule,  are 
not  followed  by  good  results,  hence  it  is  advisable  not  to  count  these  cases 
in  with  those  of  secondary  cataract:  so  that  in  speaking  of  secondary  cata- 
ract (Xachstaar).  only  those  cases  iwv  iiichuh'd  wliicli  ai'c  op('riii)lr. 


339 

a.  Thv  jMire  siveiidaiy  cataract  is  only  the  result  of  the  sequence  of 
chanoes  which  tak.'s  place' (h.rin-  and  after  an  extraction  within  the  cap- 
sule of  the  le.i>.  an.l  is  confined  to  those  portions  of  the  lens  substance 
whi.h  are  not  evacuated.  Hence,  if  one  may  so  express  it,  this  is  the 
product  of  a  pure  phakitis. 

Every  one  can  observe  how  the  lens  substance  which  escapes  from  the 
ir.lerior  of  tbe  capsule,  but  is  retained  within  the  anterior  chamber,  swells 
up  and  is  absorbed.  Every  oculist  should  see  to  it  that  the  iris  is  well 
dilated,  so  as  to  prevent  the  possible  formation  of  synechia.  If  they  are 
not  formed,  one  will  be  enabled  to  see  at  a  recognizable  distance  behind 
the  pui>il,  a  grey,  nuMnhraiious-like  cloudiness,  which  is  more  or  less  trans- 
parent, and  dependent  on  the  degree  of  its  non-transparency  vision  will 
be  pr()i)()rtionately  impaired.  If  the  pupil  is  dilated  one  can  easily  see  that 
this  cloudiness  increases  toward  the  periphery:  hence,  the  portion  which  is 
hidden  behind  the  iris  is  more  saturated  than  the  portion  in  the  pupillary 
area.  The  secondary  cataract  is  thickest  in  the  equatorial  region  of  the 
lens.  (Tlie  reason  for  this  has  been  explained  in  the  third  part  of  this 
work.)  In  llie  i)upillary  area  this  thickness  is  a  variable  quantity.  In  iso- 
lated spots  this  secondary  cataract  may  be  entirely  wanting.  At  times  such 
u  small  opening  is  sufficient  to  enable  one  to  obtain  sufficient  vision. 

The  changeable  appearance  of  the  secondary, cataract  in  the  ])upillary 
area  is  eharacteristic  of  the  pathological  changes  which  take  ])lace  in  the 
remains  of  the  lens  substance. 

The  duration  of  the  phakitis  is  variable.  True,  we  discharge  a  cata- 
ract patient  as  well,  when  the  eye  looks  pale  and  the  pupil  relatively  clear. 
Weeks  or  months  later  tlu-  patient  returns,  and  we  find  the  pupil  occulated 
by  a  thick  secondary  cataract.  Years  may  elapse  without  any  change  tak- 
ing place  in  the  degree  of  vision,  without  our  being  in  a  position  to  deter- 
mine whether  or  not  any  change  has  taken  place  in  the  secondary  cataract. 
Then  suddenly  the  patient  notices  a  gradual  diminution  in  the  amount  of 
vision,  whereas  the  accompanying  symptoms,  the  irritabihty  to  light,  the 
pain,  the  tearing  and  ciliary  injection,  may  be  so  slight  as  to  be  scarcely 
noted  by  the  patient.  If  such  a  patient  comes  under  observation  at  this 
time,  one  can  see  a  punctate,  striated,  or  spotted  cloudiness  gradually  de- 
veloping in  tlie  ])upil.  As  a  rule,  this  cloudiness  begins  near  the  point  of 
incision,  and  gradually  extends  toward  the  center  At  the  s^me  time  the 
iris  may  ap])arently  be  uninvolved.  (This  is  the  picture  of  the  tension  of 
the  cicatrized  iris  or  capsule  in  the  wound,  possibly  a  secondary  infection 
along  a  fistulous  tract.) 

There  is  a  peculiar  form  of  "di-usige"  hyaline  thickening  of  the  origi- 
nally clear  ca])snle,  which  can  lead  to  a  very  material  reduction  of  vision. 


340 

On  use  of  the  refracting  opthalmoscope  one  can  discern  these  warty  ex- 
cressences,,  and  on  moving  the  mirror  they  give  a  sliiny  reflex,  but  are 
otherwise  transparent.  Eepeated  examination  will  show  that  these  exist 
in  numbers.  These  conglomerations  cause  considerable  interference  with 
vision,  but  Becker  states  that  he  has  never  seen  them  change  to  total  opaci- 
ties. That  the  processes  which  take  place  in  a  pure  secondary-  cataract 
are  confined  to  the  capsule  of  the  lens  and  those  lens  cells  which  remain 
behind,  is  attested  by  the  fact  that  the  neighboring  tissues  are  not  involved 
in  this  inflammatory  (?)  process. 

A  secondary  cataract  always  forms  where  the  capsule  is  not  extracted. 
The  slightest  folds  in  the  capsule  cause  reflexes,  hence,  it  becomes  seK- 
evident,  that  there  must  nearly  always  be  an  improvement  in  vision  where 
the  cause  of  these  reflexes  is  removed.  But  whether  a  patient  will  desire 
a  second  operation  will  depend  largely  on  how  much  he  will  need  his  eyes. 
The  amount  of  vision  which  ought  to  be  attained  will  be  considered  later 
on.  Speaking  in  a  general  way  a  secondary  operation  is  indicated  when 
vision  is  reduced  to  6-60.  If  during  extraction  the  vitreous  puncture  (Hass- 
ner)  is  made,  and  no  reaction  follows,  vision  will  not  only  be  good,  but 
seldom  will  this  hter  be  diminished. 


COMPLICATED  CATAEACT.     PHTHISIS  BULBI  AXD 
PANOPTHALMITIS. 

These  are  conditions  which  are  but  'rarely  me:  with  at  the  present 
day,  and  only  occur  when  an  infection  takes  place. 

A  complicated  cataract  may  be  the  result  of  an  iritis.  As  has  already 
been  mentioned,  its  slightest  foi-ms  occur  very  frequently,  and  do  not 
always  lead  to  a  secondary  operation.  But  the  more  intense  the  reaction, 
the  thicker  will  be  the  secondary  cataract.  Just  as  soon,  however,  as  the 
symptoms  of  wound  reaction  set  in,  at  the  sclero-corneal  wound,  on  the 
iris,  in  the  pouch  of  the  capsule  or  in  the  ciliary  body,  the  active  develop- 
ment of  a  secondary  cataract  will  go  on,  and  finally  lead  to  occhisio  pupillae. 
According  to  the  extent  of  the  general  reaction  this  can  be  divided  into 
a  number  of  clinical  forms  of  disease.  However,  where  this  process  reaches 
a  certain  intensity,  all  those  tissues  which  were  involved  in  the  incision 
will  be  affected.  Depending  on  the  extent  of  the  general  reaction,  this 
will  lead  to  an  iritis  wifh  orrlusion  of  fhfi  pupil,  an  iridocyditis  with  occlu- 
sion of  the  pupil,  toiicllicr  irllli  llir  ^uhscijiiciil  sliriiil-di/e  of  ])ands  of  connective 
tissue  in  the  vitreous,  a  piinilciil  iufloiiinnitinn  of  the  vitreous,  euding  in 
phthisis  t)iitl)i,  and  llnally.  i,i  /»o7ioplli(ilorilis.  ilic  gi-atly  feared  total  loss 
of  the  entire  eyeball,  or  a  siippnrotiou  of  the  rorurn. 


341 
^  1.  lA't  US  iirsl  cxjimiiic  the  rli:iii-(-  which  l;ik-'  phicc  in  th.-  <-<.i-ii<'a. 
All  tlic  processes  of  woniid  iviiclion  (h'-crihcd  ;ihove  are  inteiisilled,  and 
we  liiul  tlie  tMl,a-es  of  the  wound  >u|i|iui-;it  m-.  While  snft'erinjr  from  tetir- 
ino-  and  irritability  lo  li^hl.  the  patient  coniplain>  of  pain,  the  eoiijuiietiva 
in  the  neiuhhorhood  of  the  wound,  and  the  vi\izv<  oi'  the  W(»und  tliemselves 
swell  up.  From  the  second  day  on.  the  ,urey  striations  in  ihe  eoi-nea  in- 
creasi',  assume  a  more  yellow  color,  and  linally  either  a  circunisci-ihed  por- 
tion or  the  entire  length  of  the  wound  heciunes  inllllrateil  with  pii-.  Hav- 
ing reached  this  stage  of  developnu'iit.  thi.s  process  may  come  to  a  stand- 
still on  the  third  oi-  rouitli  day.  gradually  retrogressing  again,  and  leave 
the  gi'eater  poi'lion  (d'  the  cornea  t  i-anspareiil.  Ileiv  we  always  (iiul  the 
iris,  the  capsule  sac.  and  very  ol'len,  also,  tlu'  coi-piis  eiliare  in  the  neigh- 
borhood of  the  wound  involved,  liepending  on  the  degrei;  of  the  process 
Ave  always  assume  the  involvement  of  the  above  sti-uctures:  this,  however, 
can  never  be  determined  imtil  the  coi'iu'a  has  coiumenced  to  clear  up.  To 
combat  this  sup])ni'ation  the  best  method  is  to  immediately  cauterize  the 
corneal  wound  along  its  entire  extent  with  a  galvano  caiitery.  The  an- 
terior i-hand)ei-  should,  if  not  completely  open,  be  reopened  and  washed 
out  with  a  corrosive  sublimate  solution.  As  a  linal  i-esult,  one  always  finds 
the  sclero  corneal  cicatrix  drawn  in.  and  a  thick  secondary  cataract,  which 
in  its  entire  extent,  is  everywhere  adherent  to  the  periphery  of  the  iris. 
Owing  to  the  gradual  shrinkage  of  this  secondary  cataract,  which  is  con- 
nected with  the  cicatrix  of  the  wound,  the  iris  is  gi-adually  drawn  toward 
it.  As  the  pupil  now  gradually  becomes  smaller  at  the  sides,  the  secon- 
dary cataract  likewise  appears  to  gi-ow  smallei'.  and  shows  vertical  stri- 
ations,  which  seem  to  be  continuous  with  the  sli-iations  of  the  iris,  giving 
us  the  picture  resendjling  the  ai-rangement  of  the  ribs  in  a  large  palm-leaf 
fan.  The  iris  presents  in  nnniature  the  ])icture  of  the  so  commonly  Used 
Japanese  fan. 

"Weeks  and  months  may  ]iass  before  this  process  has  run  its  course. 
All  this  time,  howevt'r.  the  tension  of  the  globe  remains  normal. 

2.  If  the  corneal  infiltration  does  not  remain  I'estricted  to  the  imme- 
diate vicinity  of  the  wound,  on  the  second  or  third  day  one  will  o1)serve 
an  extension  of  this  striated  keratitis,  until  the  entire  coi'uea  may  finally 
become  infiltrated  in  a  tongue-like  manner.  There  can  be  no  doubt  now 
as  to  the  involvement  of  the  intu'i'  portions  of  the  eye.  'I'his  can  be  deter- 
mined by  the  extensive  chemosis  and  the  ])lastic  oedematous  swelhng  of 
the  entire  conjunctiva  bulbi.  The  subjective  pluMiomena  are  also  very 
much  increased.  It  is  not  necessary  that  this  should  lead  to  complete 
suppurati(m  of  the  globe,  but  it  always  leads  to  the  formation  of  an  opaque 
corneal    cicatrix,   which  is  intimatelv   connected   with    the   ii'is.   and   to   a 


342 

thick  cyclitic  meinbianoiis  cataract.  If  after  months  the  process  finally 
becomes  quiescent,  the  globe  may  retain  its  general  form,  bnt  its  intra- 
ocular tension  will  be  found  to  be  reduced.  Notwithstanding  the  fact 
that  the  light  sense  may  still  be  present,  this  flattening  of  the  cornea, 
phthisis  corneoe,  will  cause  everj-  operation  to  be  without  result. 

3.  This  tongue-like  infiltration  of  the  corne-a  seldom  leads  to  suppu- 
ration of  the  same.  But  one  must  always  be  prepared  for  such  an  occur- 
rence, and  on  the  third  or  fourth  day  there  may  develop.  ^  mm.  removed 
from  the  corneal  edge  and  concentric  to  the  same,  a  saturated  yellow  ring- 
like cloudiness  which  is  very  pronounced  (ring  abcess  of  Yon  Graefe). 
Such  a  picture  seldom  develops  without  causing  a  necrosis  of  the  entire 
cornea,  and  the  much  feared  panopthalmitis.  An  ill  omen  which  appears 
at  the  same  time,  together  with  a  flabby  oedematous  swelling  of  the  con- 
junctiva, is  a  very  profuse  blenorrhoeic  secretion  from  the  same.  Naturally, 
such  a  profuse  purulent  infiltration  of  the  cornea  is  from  the  very  be- 
ginning associated  with  a  purulent  inflammation  of  the  iris,  the  corpus 
ciliare,  the  choroid,  the  retina,  the  vitreous,  and  evei.  the  sclerotic.  We,  how- 
ever, only  make  a  diagnosis  of  panopthalmitis,  when  a  protrusio  hdbi,  a 
slight  exopthalmus  is  added.  This  latter  condition  is  the  symptom  .which 
tells  us,  that  the  purulent  inflammation  has  extended  beyond  the  borders 
of  the  'eyeball,  and  that  it  has  invaded  the  lymph  sac  of  Tenon's  capsule, 
and  possibly  has  extended  into  the  orbital  tissue. 

Von  Graefe  (1.  c,  p.  189)  has  given  us  the  foUowins  classical  description  of 
the  symptoms  which  a  case  of  panopthalmitis  presents:  "After  a  more  or  less 
indifferent  course  of  twelve  to  eighteen  hours,  seldom  thirty  hours,  a  gradually 
increasing  SAvelling  of  the  upper  lid.  togetlier  with  the  formation  of  a  consider- 
able quantity  of  thin,  dirty,  yellowish  pus  develops.  This  latter  consists  less 
of  the  secretion  of  the  tear  glands  than  of  a  transudation  from  the  conjunctival 
.surface,  which,  together  with  the  epithelial  detritus  and  pus  cells,  forms  a  some- 
what even  emulsion.  There  may  be  but  little  pain  at  this  time.and  this  may 
depend  on  the  faint  reduction  (tf  Ihc  general  s('nsil)ility  in  such  i»a1ients.  If 
one  separates  the  lids  at  the  vei-y  lieginning  of  the  disease,  a  jiortion  of  tlie 
secretion  which  was  hidden  beneath  the  lids  will  well  forlli.  At  tliis  time 
neither  corneal  wound  nor  pupil  sliow  any  i>ar(icuhir  .-inonialy.  However,  the 
entire  anterior  surfjice  of  tiie  eye  lias  a  most  ]>eculiar  yellowish  <-o!oi-.  d\ie  to 
the  excessive  hlling  of  tlie  lymph  sp.-ices  in  ItoIJi  conjunctiva  and  coi'nea.  The 
general  swelling  of  tlie  former,  and  tlu'  adhei-ence  of  tlie  ••li(iui(l  mass"  (o  its 
surface,  gives  the  eye  the  ominous  '"waslied  out"  appearance.  The  yellowish 
discoloration  of  the  cornea  is  due  to  tlie  tilling  up  of  its  lymph  spaces  with  a 
yellowish  material.  Although  these  "tubes"  seem  to  lie  liiled  with  purulent 
matter  in  the  most  pregnant  manner,  nevertlieless.  in  tlie  beginning  this  is  a 
very  lliin  layer,  so  tluit  on  tlirowing  the  light  on  the  conie.-i.  this  lias  .-i  "steam- 


343 
in,:;"  appearaneo.  Even  with  tliis  condition  present  tlie  anterior  chamber  may 
be  fully  restored,  for  truly  this  is  usually  the  case;  but  tliere  may  still  be  a 
fistulous  openinjr.  Wlietlier  tlie  on<'  or  tlic  other  condition  is  present  depends 
largely  on  the  intra-ocular  pressure;  partly,  also,  on  the  condition  of  the  surface 
of  the  wound;  Where  tliis  infiltration  develops  suddenly  and  intensely  on  the 
edges  of  the  sclero-eorneal  wound,  iind  also  in  tin-  subconjunctival  portion,  this 
will  lead  more  easily  to  closure  of  tiie  iintnior  (Miaiuber:  whereas,  if  the  process 
spreads  more  rapidly  along  the  surface,  ilie  anterior  chamber  will  not  be  so 
easily  resored.  and  will  soon  lead  to  a  culminating  point." 

4.  At  times  one  can  di&eover  important  phenomena  on  the  iris  before 
the  cornea  is  involved,  or  shows  any  signs  of  cloudiness.  In  the  beginning 
the  aqueous  is  cloudy,  the  iris  discolored,  and  shows  signs  here  and  there 
of  yellowish  spots,  and  tinally  hypopyon  develops,  a  true  acute  suppurative 
iritis.  Later  on  the  cornea  becomes  cloudy  in  its  entire  extent,  but  ne- 
crosis of  the  same  seldom  follow^s.  Frequently  the  wound  which  has  closed 
opens  up  again,  and  a  drop  or  two  of  pus  will  be  found  exuding  from  the 
wound. 

It  is  possible  for  a  case  of  suppurative  iritis  to  heal  with  a  perfect 
retention  of  form,  normal  tension  of  the  globe,  light  sense  retained  and 
good  projection.  But  nearly  always  there  is  developed  a  thick  secondary 
cataract,  in  the  fonnation  of  which  the  ciliary  body  participates;  still,  I 
have  seen  cases  attain  perfect  restitution  of  sight  without  undergoing  a 
second  operation. 

It  goes  without  saying  that  the  capsule  plays  a  very  important  role 
in  the  entire  process.  It  depends  entirely  to  how  great  a  degree  the  cihary 
body  is  involved,  how  thick  the  cyclitic  bfjids  behind  the  lens  are.  whether 
the  vessels  in  the  same  will  become  obliterated,  and  whether  the  vitreous 
body  will  shrink,  what  degree  of  benefit  operative  interference  would  give 
to  the  patient.  An  estimate  concerning  these  concUtions  in  an  eye  may 
be  formed  by  testing  the  tension  of  the  globe.  Whether  nn  eye  can  be 
made  to  see  or  not,  depends  on  these  factors. 

■").  Cyclitis  assumes  an  important  role,  and  in  the  cases  in  whit-h  kera- 
titis and  iritis  ai-e  most  pronounced,  the  prognosis  largely  depends  on  the 
development  of  this  complication,  l^ut  cyclitis  may  disclose  itself  as  the 
primary  and  most  important  sym]itom,  and  in  a  very  severe  form. 

In  such  a  case,  during  the  first  few  days,  neither  cornea,  iris  or  pupil 
will  show  any  suspicious  signs.  It  is  only  after  one  believes  that  all  the 
danger  is  past,  that  on  the  fourth  or  fifth  day  the  eye  becomes  reddened. 
Whereas  the  cornea  appears  clear,  the  iris  begins  to  take  on  a  darker  color, 
and  the  pupil  begins  to  show  a  tendency  not  heretofore  observed  to  cata- 
ract, and  the  subjective  symptoms  irritability  to  liglit.  spontaneous  pain 


344 

and  tendiTiiess  to  pressure  beoin  to  develo]).  Tu  t\m  may  be  added  a 
gradual  liyperplasia  of  the  cells  m  the  capsule,  and  even  to  a  greater  for- 
mation of  flakes  in  the  vitreous;  likewise,  an  exudation  in  the  anterior 
chamber,  as  well  as  a  simple  cloudiness  of  its  contents,  to  which  may  be 
added  pus  and  1)lood. 

The  characteristic  feature  of  this  process  is  its  exceptional  olistinacy. 
Notwithstanding  all  this,  it  may  cease  after  uu)nths.  leaving  but  a  very 
delicate  secondary  cataract,  which  even  in  a  case  where  exceptional  require- 
ments are  made  of  the  eye,  would  not  require  a  subsequent  secondary  cata- 
ract. On  the  other  hand,  it  may  lead  to  a  thick  secondary  cataract,  ad- 
herent to  the  iris  and  cyclitic  bands,  and  even  finally  result  in  phthisis  hulhi. 
This  latter  condition  even  develops  very  late.  Such  a  result  is  to  be 
feared  where  tenderness  to  pressure  will  not  cease.  This  process  may  be 
complicated  by  detachment  of  the  retina  and  internal  hemorrhages,  thus 
finally  necessitating  enucleation. 

G.  The  vitreous  body  may  become  primarily  afl'ected  without  either 
iris  or  cornea  being  primarily  affected.  This,  as  a  rule,  occurs  when  there 
has  taken  place  a  prolapse  of  tlie  vitreous.  Becker  states  that  this  has 
occurred  in  cases  in  wliich  the  hyah)idea  had  not  ruptured,  and  the -vitre- 
ous had  simply  been  exposed  as  a  vesicle  in  the  wound.  Such  a  heimia 
corporis  vitrei  can  only  occur  where  a  tear  in  the  zonula  has  taken  place. 
On  the  second  day  one  can  see  yellowish  grey  shreds  extending  from  the 
pupil  into  the  vitreous.  The  wound  gaps  and  flakes  of  pus  exude.  In  a 
short  time  the  entire  pupil  is  filled  with  pus,  the  iris  discolored  is  pressed 
forward,  and  the  conjunctiva  is  chemotic.  It  is  a  very  noteworthy  fact, 
that  though  the  cornea  may  be  pressed  forward  to  such  an  extent,  by  the 
pus  in  the  anterior  (•haml)er  as  to  form  a  perfect  angle,  it  nevertheless 
retains  its  trans])arency  except  along  a  narrow  edge,  along  the  line  of  the 
incision,  so  that  it  is  possible  to  observe  accurately  and  follow  up  the 
gradual  vascularization  of  the  pupillary  edge  of  the  iris,  and  also  the  de- 
velopment of  blood  vessels  in  the  purulent  mass  in  the  pu])illary  area. 
Naturally,  swelling  up  of  the  lids  and  plastic  chemosis  are  ])resent.  but 
only  to  a  inodei'ate  degree.  The  globe,  however,  under  all  circumstances, 
retains  ils  niol)ility,  and  a  prolrvsio  huttn  never  occurs.  Sensation  to  light 
may  be  relained  for  a  few  days,  but  disa])pears  on  the  fourth  or  fifth  day. 

It  is  possible  for  sncli  a  ])urulent  inflammation  of  the  vitreous  to  be 
followed  by  total  retention  of  the  form  of  the  glob?  of  sensation  to  light. 
and  even  normal  tension.  In  these  cases  the  wound  clpses  toward  the  end 
of  the  second  week  witliont  the  develo])ment  of  increased  intra-ocular 
tension.     In  llicsc  cases  one  is  justified  in  the  belief  that  the  process  wa.s 


I 


345 
restricted  to  the  anterior  half  of  the  vitreous.  As  a  rule,  in  course  of  time 
diminished  intra-ocular  tension  develops. 

If  this  discharge  of  pus  continues  for  any  lenoth  of  time,  sensation 
to  lio-ht  will  be  totallv  abolished,  even  before  the  wound  closes,  more  fre- 
quentiy,  however,  after  it  has  closed.  During  this  time  the  eye  has  a  hard 
peculiar  increased  resistance  to  the  touch.  It  does  not  feel  hard,  but  gives 
one  the  impression  that  its  coats  hdve  lost  all  their  elasticity. 

The  further  course  continues  but  slowly.  The  pains,  which  have 
never  been  severe,  after  the  wound  closes  become  markedly  increased.  As 
a  consequence,  the  general  health  of  the  patient  does  not  suffer,  and  the 
absence  of  pain  helps  to  keep  up  his  hope.  When  the  last  exacerbation  of 
pain  ceases,  the  swelling  of  the  lids  disappears.  The  infiltration  of  the 
conjunctiva  continues,  although  the  oedema  disappears.  Gradually  the 
anterior  chamber  is  restored,  the  vessels  of  the  iris  and  pupillary  area  are 
no  longer  visible,  the  tissue  which  occludes  the  pupil  gradually  assumes 
a  grey  color,  and  is  reduced  to  a  small,  vertical  band.  From  now  on  the 
tension  of  the  globe  gradually  diminishes,  and  phthisis  corneae  and  hulbi 
develop.  Six  to  eight  weeks  elapse  before  the  recti  muscles  begin  to  leave 
their  impress,  and  months  pass  before  the  process  of  shrinkage  comes  to  a 
close.  During  all  this  timethe  eye  is  moderately  sensitive,  the  conjunctiva 
especially  around  the  cornea  is 'deeply  injected,  and  as  a  rule  the  palpebral 
fissure  is  kept  closed. 

7.  Hemorrhages  which  occur  during  the  process  of  healing  are  to  be 
differentiated  from  those  which  have  already  been  mentioned.  They  have 
never  been  observed  following  a  flap  extraction  unless  associated  with  a 
rupture  of  the  wound  or  due  to  a  trauma.  Hence  it  seems  we  must  seek 
their  cause  in  the  peripheric  position  of  the  incision  and  the  iridectomie. 
This  same  occurrence  has  been  noted  where  a  simple  iridectomie  is  made. 
Not  unfrequently  they  pass  off  without  any  evil  consequences,  especially 
when  the  hemorrhage  has  been  a  slight  one,  but  where  this  has  been  severe 
it  is  nearly  always  followed  by  iritis  (Snellen).  But  if  hemorrhages  which 
appear  to  be  very  severe  recur,  they  may  lead  to  very  unpleasant  results. 

As  a  rule,  these  hemon-hages  take  place  in  ihe  anterior  chamber, 
much  less  frequently  do  they  occur  as  minute  or  large  ones  into  the  ritre- 
ous.  The  prognosis  becomes  all  the  -worse,  the  more  reason  one  finds  for 
their  not  being  the  result  of  trauma.  It  can  not  be  doubted,  that  especially 
during  sleep,  patients  unconsciously  rub  the  healing  eye.  At  times  they 
admit  it.  If  we  will  eliminate  these  eases,  the  following  cause  may  be 
enumerated  with  more  or  less  certainty: 

(1)  Eepeatedly  have  such  hemorrhages  been  observed  where  the  an- 
terior chamber  was  suddenly  restored,  after  having  been  abolished  for  a 


346 

considerable  length  of  time.  The  hemorrhages  were  never  great,  and  never 
were  followed  by  evil  conseqnences.  It  seems  probable  that  the  tension 
which  is  exerted  on  the  iris,  where,  owing  to  the  accumulation  of  aqueous, 
it  is  forcibly  pressed  backward,  one  of  the  new  formed  blood  vessels  is 
ruptured,  and  thus  gives  rise  to  the  hemorrhage.  The  patients  always 
state  that  they  felt  a  sudden  pain. 

(3)  If  at  times,  or  shortly  after  the  hemorrhage,  an  iritis  develops,  it 
is  more  than  likely  that  the  hemorrhage  is  the  result  of  a  previous  hyper- 
aemia  of  the  iris,  especially  since  cases  of  iritis  have  been  observed  in  which 
hemorrhages  did  occur  when  no  operation  had  been  made.  Owing  to  the 
great  rarity  of  spontaneous  hemorrhage  in  iritis  following  extraction,  one 
must  assume  as  a  second  cause  diseased  friability  of  the  blood  vessels  of 
the  iris. 

(3)  Together  with  Knapp  (A.  f.  A.  and  0.,  I.  p.  54)  Becker  considered 
a  predisposition  to  hemorrhage  as  the  main  cause  of  those  hemorrhages 
which  are  restricted  to  the  anterior  chamber,  and  which  become  danger- 
ous, owing  to  their  recun-ence,  and  which  may  likewise  take  place  in  the 
vitreous.  Those  cases  of  cloudiness  of  the  vitreovis  reported  by  Knapp 
(1.  c,  p.  57).  are  most  easily  accounted  for  in  this  manner.  According  to 
Knapp  such  hemorrhages  offer  a  veij  had  prognosis.  The  cause,  most 
certainly,  is  a  diseased  condition  of  the  vessels  which  existed  before  the 
operation,  and  this  can  not  always  be  diagnosticated.  The  final  result 
need  not  always  be  a  sad  one,  as  was  demonstrated  to  me  (Becker)  in  a 
case  in  which,  on  the  fourth  day,  a  large  hemorrhage  took  place  in  the 
vitreous  and  in  the  onierior  chamber,  accompanied  by  the  most  violent 
pains,  without  a  rupture  of  the  wound  taking  place,  and  only  a  quanti- 
tative perception  of  light  remained.  The  blood  in  the  anterior  chamber 
soon  disappeared,  though  the  resorption  of  the  blood  in  the  vitreous  re- 
quired months;  nevertheless,  finally  a  very  satisfactory  amount  of  vision 
was  restored.  In  operating  on  the  second,  a  preliminary  iridectomie  was 
made,  and  the  eye  healed  without  an  accident. 

The  opinion  lias  been  expressed  personally  to  me  (Becker),  that  the  venous 
plexus  of  Leber  is  incised  during  the  operation,  and  that  the  hemorrhage  may 
arise  from  this  cause.  However.  I  have  never  found  such  a  condition  present 
as  would  warrant  such  a  conclusion  in  the  innumerable  microscopical  sections 
which  I  have  examined. 

8.  The  relative  frf-quency  of  the  above  described  processes  of  healing, 
especially  those  in  wliicli  a  good  result  is  not  attained,  is  dependent  to  a 
large  degree  on  the  manner  of  procedure  during  the  operation:  hence,  to 
speak  more  plainly,  on  the  operator  himself.  In  no  department  of  opthal- 
mology  docs  the  difference  between  the  master  and  the  novice  become  more 


347 
apparent  than  in  .be  operative,  and  here,  above  all.  m  the  ,K.rfornmnce  of 
a  cataract  extraction.  But  even  in  the  hands  of  the  most  skillful  all  cases 
which  have  apparently  had  a  similar  result,  after  being  operated  accord- 
ing to  the  same  method,  do  not  attain  a  simila.-  final  result.  Different 
individuals  after  undergoing  a  simi^lar  operation  react  differently.  This 
idea  has  already  been  expressed.  \\  here  it  became  necessary  to  separate  the 
simple  from  the  complicated  cataracts.  Likewise,  the  fact  deserves  men- 
tion here,  that  the  second  affected  eye  offers  a  bettei-  prognosis  than  the 
first  affected.  In  many  cases  the  individuahty  of  the  operated  eye  is  re- 
sponsible for  a  poor  result. 

Becker,  as  the  result  of  the  microscopical  examination  of  human  eyes 
which  had  been  operated  on  for  cataract,  and  also  of  pigs'  eyes,  on  which 
he  had  experimentally  operated,  makes  the  following  important  obser- 
vations: 

Accurate  measurements  regarding  the  position  of  the  various  forms 
of  incision  in  the  edge  of  the  cornea  have  shown  very  interesting  differ- 
ences between  the  Daviel  and  the  Graefe's  incision.  In  making  a  flap  ex- 
iraction,  the  outer  edge  of  the  wound  should  not  touch  the  limbus.  In 
three  eyes  examined  the  wound  lay  1  mm.  from  the  limbus;  the  inner  edge 
of  the  wound,  therefore,  lay  2-2.35  mm.  distant  from  the  insertion  of  the 
iris.  This  is  ahout  the  condition  which  should  exist  where  the  operation 
is  made  according  to  the  rule  laid  down.  In  the  Graefe  extraction,  where 
the  outer  edge  of  the  wound  falls  in  the  limbus,  one  is  less  in  a  position 
to  measure  its  distance  from  the  edge  of  the  cornea.  The  mean  distance 
of  the  inner  edge  of  the  wound  from  the  iris  is  equal  to  about  1.25  mm. 
If  a  so-called  negative  incision  is  made,  it  is  found  to  lie  anterior  to  the 
limbus,  in  the  cornea,  and  in  carrying  out  this  method  the  inner  edge  of 
the  wound  is  farther  removed  from  the  insertion  of  the  iris. 

Frequently  a  glance  at  the  corneal  cicatrix  will  sufhce  to  show  us  the 
method  which  was  employed  in  operating.  A  flap  extraction  made  with 
a  Beer  knife  goes  through  a  line  which  forms  an  angle,  of  varying  degree, 
with  the  radius  of  the  cornea,  hence  has  an  oblique  direction,  and  is  con- 
siderably broader  than  the  thickness  of  the  cornea.  It  lies  in  a  single 
plane,  and  in  transverse  section  shows  lliat  it  does  not  change  its  direction. 
However,  in  the  Graefe  operation,  after  making  the  eontra-punctiire,  the 
knife  must  be  turned  so  that  the  cutting  edge  looks  antei-inrly.  In  doing 
this  it  is  not  always  possible  to  do  so  without  changing  the  direction  of 
the  cutting  edge  of  the  knife  several  times.  On  section  we  get  an  angular 
cicatrix,  if  the  section  is  taken  from  the  point  where  puncture  or  counter- 
puncture  was  made.     But  we  can  even  recognize  a  Graefe  incision  in  the 


348 

section,  where  this  is  taken  from  the  center  of  the  line  of  incision,  because 

this  is  always  more  perpendicular  to  the  surface  of  the  cornea. 

An  angular  condition  of  the  incision  must,  under  certain  conditions, 
act  as  a  hindrance  to  an  exact  adaptation  of  the  two  surfaces  of  the  wound. 

The  tendency  of  a  corneal  wound  to  open  again  is  dependent  on  the 
height  of  the  flap.  This  tendency,  however,  is  increased  by  the  fact  that 
the  two  surfaces  where  these  lie  in  a  single  plane  glide  past  each  other 
more  easily,  and  give  more  easily  to  the  intra-ocular  pressure  than  where 
the  two  surfaces  fit  into  each  other  by  means  of  an  angle.  This  tendency 
of  the  corneal  portion  to  glide  past  the  scleral,  exists  both  in  practicing  the 
Daviel,  and  the  Graefe  method  of  eairaction.  But  under  like  conditions  this 
gliding  past  each  otlier  seems  to  be  greater  where  the  flap  extraction  is 
made,  than  where  a  peripheral  linear  incision  is  made.  According  to 
measurements,  this  difi'erence  varies  from  0.12  to  0.30  mm.  The  younger 
the  individual,  and  the  more  recent  the  cicatrix,  the  greater  will  be  the 
dislocation;  but  it  appears  that  in  course  of  time,  this  may  equalize  itself 
again.  The  astygmatism  which  develops  after  an  extraction  depends  partly 
on  this  fact.  But  the  most  inconsiderable  thickening  of  the  corneal  tissue 
along  the  line  of  the  wound  is  not  without  its  influence.  Both  have  a  ten- 
dency to  grow  less  in  the  course  of  a  few  months.  In  cases  where  the 
capsule  of  the  lens,  or  the  iris,  cicatrize  in  the  wound,  the  corneal  tissite 
undergoes  greater  reaction,  and  the  curvature  of  the  cornea  may  be  con- 
siderably altered. 

lEREGULAR  HEALING  OF  THE  WOUNDS.  The  normal  pro- 
cesses of  healing  of  a  corneal  wound,  may  be  modified  or  interfered  with 
by  the  entrance  of  foreign  substances  between  the  surfaces  of  the  wound. 
This  is  aided  by  the  peripheral  position  of  the  wound,  and  the  combining 
of  the  operation  of  iridectomie  with  that  of  extraction.  As  a  rule,  such  a 
wound  heals  slower,  and  though  the  final  amount  of  vision-  may  be  good, 
still  during  the  first  few  months  this  acquired  asymetry  of  the  cornea  will 
make  itself  very  evident  to  the  patient  by  its  interference  with  sight.  In 
such  a  cicatrix  we  must  seek  for  the  causes  w^hich  produce  signs  of  irrita- 
tion, which  may  not  begin  to  manifest  themselves  until  long  afterward, 
and  which,  together  with  other  pathological  conditions  which  may  follow 
in  their  track,  may  finally  become  fatal  to  the  existence  of  the  eye,  and 
even  threaten  the  other  eye. 

].  PigiriPfilntiov  of  the  Cicatrix.  In  every  case  where  an  iridectomie 
is  made,  in  drawing  cut  tlio  iris  and  cutting  it  ofl",  some  of  the  pigment  is 
brushed  off  in  the  wound,  cicatrized  there,  and  these  pigment  cells  begin 
to    undergo   a    liyper])lasia.      Even    where   n    flap    extraction    without  iri- 


349 

dectomie  i.  made,  tlie  iris  may  iirolaps,-.  thus  reccssitating  its  rq.la.-cneiit, 
hence  the  pigmentation  whore  no  iridccl.Miiie  lias  heen  made. 

Where  the  process  is  in  other  respects  pn-fctly  n..rnial.  the  pigment 
is  found  as  small,  black  granules  in  the  cieatrix;  not  ..nly  in  the  intra- 
cellular substance,  but  within  the  cells  tlieniselves.  Hence,  it  can  not  be 
surprising  if  isolated  granules,  carried  hy  the  lynipli  stream,  are  found  in 
the  corneal  substance  itself.  This  i)igiuent  does  not  in  any  way  interfere 
with  the  perfect  healing  of  the  wound. 

2.  Cicatrization  of  the  iris  in  the  wound.  The  more  peripheric  the 
incision,  the  more  apt  is  this  to  occur.  Becker  states  that  in  seventeen 
anatomical  examinations  of  eyes  operated  by  the  flap  method,  the  iris  was 
held  in  connection  with  the  cicatrical  tissue  of  the  cornea  but  three  times, 
whereas  in  fifteen  peripheral  linear  extractions,  this  condition  was  met 
with  ten  times.    The  manner  of  its  enclosure  may  be  a  three-fold  one. 

In  both  methods  it  is  possible  for  the  iris  to  prolapse  into  the  wound 
and  cicatrize  there.  It  will  then  depend  on  the  extent  of  the  enclosure 
and  the  depth  to  which  the  iris  fills  out  the  wound,  how  great  the  inter- 
ference with  the  normal  processes  of  healing,  and  how  great  will  become 
the  density  of  the  new-formed  interstital  tissue.  Ever  since  extraction  has 
been  practiced,  has  the  attempt  been  made,  to  avoid  the  formation  of 
staphylomata.  Hence  the  necessity  for  making  a  clean-cut  excision  of  the 
iris;  a  care  to  prevent  this  cicatrization  of  the  iris  in  the.  wound.  The  fre- 
quency of  this  latter  condition  is  shown  by  anatomical  examination  to  be 
very  great. 

CONDITIONS  OF  THE  CAPSULE.  Immediately  after  an  extrac- 
tion, the  incised  anterior  capsule,  in  the  pupillary  area,  is  in  contact  with 
the  posterior  surface  of  the  cornea,  whereas  in  the  peripher}-  it  is  in  con- 
tact with  the  posterior  surface  of  the  iris.  Being  separated  only  from  the 
anterior  capsule  by  the  lens  substance  which  has  remained  behind,  the 
posterior  capsule  is  forced  against  the  anterior,  by  the  vitreous  which 
presses  forward.  The  posterior  capsule,  which  formerly  was  convex  on 
its  posterior  surface,  now  is  convex  anteriorly.  This  must  likewise  be  the 
case  with  the  hyaloidea.  In  place  of  a  fossn  patellaris.  we  now  have  a 
coUiciilvs.  From  now  on,  the  radius  of  curvature  coincides  almost  with 
that  of  the  posterior  surface  of  the  cornea. 

These  conditions  are  all  changed  as  soon  as  the  coi'neal  wound  heals, 
for  the  aqueous,  as  it  accumulates,  pushes  the  iris  and  capsule  backward 
again.  If  finally,  in  the  strict  sense  of  tlie  word,  a  sim])le  secondary  cata- 
ract (see  page  389)  forms,  this  will  he  found  removed  al)oni  1  mm.  pos- 
teriorly from  the  posterior  surface  of  the  iris.     The  catisule  of  the  lens 


350 

owing  to  the  loss  of  its  contents,  and  which  'gave  it  support,  will  appear 

folded. 

Owing  to  the  insertion  of  the  zonula  fibres,  the  so-called  fixed  points 
can  not  alter  their  position;  or  if  they  do  this,  they  approach  each  other 
and  cause  folds.  This  folding  will  be  more  apparent  in  the  pupillary  area 
than  in  the  region  of  the  crystalline  pearls. 

Owing  to  the  incision  of  the  anterior  capsule,  its  condition  is  a  com- 
plicated one.  This  condition  assumes  great  importance  when  we  bear  in 
mind  that  a  piece  of  the  anterior  capsule  may  cicatrize  in  the  corneal 
wound. 

In  order  to  prevent  this,  some  idea  should  be  had  as  to  the  proper 
position  of  incising  the  capsule,  which  is  only  reached  under  difficulties. 
Gayet  attempted  to  solve  this  question  in  an  experimental  way,  and  Becker 
states,  since  he  could  not  obtain  a  copy  of  this  work  he  made  similar  ex- 
periments, using  pigs'  eyes  (as  fresh  as  possible).  Extractions  were  made 
according  to  the  various  methods,  and  using  various  instruments  to  open 
the  capsule.  The  eyes  were  then  hardened  in  Muller's  fluid  and  then  ex- 
amined. 

All  varieties  of  the  cystotome  were  used,  and  on  making  a  simple 
movement,  merely  a  jagged  angular  wound  was  made,  the  base  of  wliich  is 
perpendicular  to  the  j)osition  in  which  we  permit  the  instrument  to  act  on 
the  capsule.  Per  example — If  the  instrument  is  passed  through  the  corneal 
incision  directly  to  the  opposite  side  of  the  pupil,  and  the  incisions  made 
exactly  upward,  we  will  find  that  we  obtained  a  triangular  flap  with  its  base 
horizontally  placed.  If  the  lens  is  now  extruded  through  this  three- 
cornered  opening,  the  base  will  become  enlarged,  the  flap  turns 
over  outwardly  and  is  in  great  danger  of  remaining  in  the  wound.  If,  on 
the  contrary,  the  instrument  is  passed  horizontally  across  the  capsule,  we 
get  a  three-cornered  flap  with  its  base  vertically  placed.  If  .the  lens  is  now 
extruded,  the  capsule  will  be  torn  vertically  to  the  corneal  incision,  conse- 
quently this  flap  will  be  pushed  to  one  side  and  will  not  be  able  to  get 
into  the  wound.  One  can  judge  how  much  depends  on  the  sharpness  of 
the  cystotome  from  the  fact  that  it  can  be  felt  to  take  hold  and  let  go  of 
the  capsule  several  times  before  it  finally  penetrates  and  tears  it. 

From  such  incisions  and  tears  as  have  been  described,  one  can  easily 
see  that  these  flaps  have  a  tendency  to  turn  over  outwardly.  If.  instead  of 
a  single  incision  or  tear,  a  number  are  made,  these  can,  without  difficulty, 
be  brought  in  ooniu'cliou  witli  the  numlier.  form  and  condition  of  the 
flaps.  In  general,  liowevei-.  tlie  I'elationsliip  is  the  same;  the  flaps  are 
turned  outwardly  and  show  rre(|nenl  iiiid  irregular  folds. 


351 

All  the  staleiiu'iits  n-anling  tlie  cicalri/.alion  of  the  capsule  in  the 
wound  were  substantiated  l.y  the  exi.erinu.ntal  investi-aticns  made  on  pigs' 

eyes. 

Adam  Weber's  and  A.  \V."s  experiments  are  to  he  mentioned  here. 
They  removed  entire  pieces  of  the  anterior  capsule  from  the  eye,  before 
delivering  the  lens.  In  cases  of  so-called  thickened  capsule,  this  can  be 
done  without  any  gr.-at  ditruulty.  At  limes  this  will  lead  to  the  desired 
end.18 

THE    COMPLICATED    SECONDAKY    CATARACT.     (CATARACTA 
SECUNDARIA  ACCRETA.) 

Strictly  speaking,  a  single  synechia  between  the  edge  of  the  pupil  or 
the  side  of  the  coloboma,  and  the  secondan^  cataract,  is  sufficient  to  bring 
the  latter  within  this  class,  though  in  every  other  respect  this  is  a  simple 
secondary  cataract  so  far  as  the  processes  within  the  capsule  are  concerned. 
Such  a  synechia  may  influence  the  position  and  the  form  of  the  secondary 
cataract.  The  frequency  of  the  adhesion  between  iris  and  capsule  is  well 
known  to  all  observers.  As  has  already  been  repeatedly  stated,  frequently 
the  capsule  cicatrizes  :n  the  corneal  wound,  and  thus  complicates  not  only 
the  wound,  but  the  cataract.  In  most  of  these  cases,  the  stump  of  the  iris 
is  likewise  involved,  and  in  these  cases  the  enclosure  of  iris  and  capsule  are 
responsible  for  the  increased  reaction  which  leads  to  the  formation  of  a 
cicatrical  secondary  cataract,  which  takes  its  origin  either  in  the  cqmea 
or  iris.  In  some  cases  the  ciliary  body  is  likewise  involved  in  this  low 
grade  inflammation,  which  leads  to  the  formation  of  connective  tissue 
bands,  which  are  stretched  across  the  eye  posteriorly  to  the  posterior  cap- 
sule and  connected  with  the  same. 

Owing  to  the  involvement  of  the  cornea,  iris,  ciliary  body  and  the 
capsule  of  the  lens,  in  such  a  secondary  cataract,  one  can  easily  comprehend 
why  it  is  that  such  an  inflammatory  process  will  only  cease  after  weeks,  or 
even  months.  The  more  complicated  the  structure  which  takes  part  in  the 
formation  of  the  cicatrix,  the  more  intense  will  be  the  shrinkage  which 
Mall  follow,  and  it  is  possible  for  the  secondary  cataract  which  is  cicatrized 
in  the  wound,  to  be  drawn  in  toto  to  the  side  of  the  wound,  so  that 
"Petit's  Canal"  may  be  widened  to  an  extreme  degree  on  the  side  directly 
opposite  the  wound.  This  will  explain  the  fact,  why  it  hap])ens,  that  at 
times,  where  a  complete  occlusion  of  the  pupil,  following  a  cataract  ex- 
traction, exists,  and  a  coloboma  is  made  diametrically  opposite  the  original 
incision,  a  space  will  be  found  which  is  entirely  free  of  the  secondary 
eataxact. 

18  Nagel's  Yahresberieht,  1870,  p.  393. 


352 

Histologically,  these  complicated  secondary  cataracts  are  made  up,  not 
only  of  the  products  of  lens  substance,  but  of  those  of  iritis,  cyclitis  and 
keratitis.  Hence  it  is  evident,  why  in.  such  secondary  cicatrical  cataracts, 
aside  from  the  elements  described  as  occun-ing  in  simple  secondary  cata- 
ract, we  here  find  connective  tissue,  pigment,  blood  vessels,  even  new- 
formed  bone. 

SEQUELAE  OF  TENSION  AND  SHEINKAGE  OF  THE  CATA- 
EACTA  SECUNDAEIA  ACCEETA.  The  evil  results  of  a  secondary 
cataract,  which  is  attached  to  neighboring  structures,  are  not  alone  confined 
to  interference  with  vision.  Only  too  often  do  we  find,  in  this  attachment, 
and  shrinkage  of  this  cicatrical  tissue,  which  in  course  of  time  must  follow, 
the  destructive  element  which  in  course  of  weeks  not  only  threatens  to 
destroy  the  pe]-ception  of  light,  but  which  leads  to  recurring  infiammation 
which  may  finally  totally  destroy  the  shape  of  the  eyeball.  And,  what  is 
still  worse,  the  painful  signs  of  irritation  which  are  the  result  of  the  shrink- 
age of  the  secondary  cataract,  which  may  lead  to  sympathetic  irritation  of 
the  second  eye. 

A  single  simple  posterior  synechia  changes  the  normal  position  of 
the  secondary  cataract,  in  that  it  is  drawn  forward.  In  its  turn,  this  causes 
the  formerly  perfectly  flat  anterior  surface  of  the  vitreous  to  become  more 
or  less  convex.  The  vitreous,  however,  may  form  a  slight  convexity  in  the 
fossa  patellaris,  even  where  no  adhesions  have  formed,  and  in  cases  in  which 
the  crystalline  pearl  is  very  thick. 

If  the  secondary  cataract  is  very  thick  and  posterior  synechia  exist, 
the  iris  may  be  drawn,  funnel-like,  backward — a  condition  which  is  met 
with  at  times. 

The  greater  the  amount  of  new-formed  tissue  in  this  secondary  cata- 
ract, the  greater  will  be  the  extent  of  its  shrinkage,  and  the  longer  will  the 
irritation  continue,  which  will  be  exerted  on  the  ciliary  body.  In  the  few- 
est cases  will  this  irritation  be  ended  at  the  time  the  patient  is  discharged 
from  the  physician's  care.  Though  accommodation  no  longer  exists  after 
a  cataract  extraction,  nevertheless,  the  muscular  contractions  of  the  ciliary 
body  undoubtedly  go  on,  when  an  attempt  is  made  to  see  objects  distinctly 
w'hich  are  close  by;  hence  this  will  also  explain  the  evil  results  which  may 
be  exerted  as  a  result  of  stopping  the  use  of  atropine  too  soon;  likewise,  by 
permitting  the  patient  to  use  his  cataract  glasses  too  soon. 

In  complicated  cataracts,  the  conditions  are  still  more  unfavorable, 
since  the  ciliary  lody  noi  only  draws  on  iho  corneal  cicatrix,  through  the 
medium  of  the  zonula,  but  also  by  means  of  the  iris  attached  to  the  cap- 
sule. Hence  in  such  cases  the  indications  are  to  leave  the  eye  at  rest  as 
long  as  possible. 


353 

CYCLITIS.  Th.-  products  have  already  Ix'cn  considered  in  speaking 
of  complicated  cataracts.  Here  we  must  difi'erentiate  between  the  direct  in- 
fluence of  those  lighter  forms  involved  in  the  formation  of  secondary  cata- 
ract and  those  severe  forms  due  to  infection  which  U.ul  to  purulent  degen- 
eration of  the  vitreous  and  panopthalmitis;  and,  further,  those  changes 
which  are  due  to  the  shrinkage  of  these  cyclitic  products  and  lead  to  detach- 
ment of  the  ciliary  body  and  detachment  of  the  retina. 

DETACHMENT  OF  THE  VITREOUS.  This  may  occiir  in  a  two- 
fold manner;  it  may  he  acute  or  primary,  chronic  or  secondary.  Iwanoff 
found  in  quite  a  number  of  cases  which  seemed  to  have  healed  under  per- 
fectly normal  conditions,  twelve  to  twenty  days  after  extraction,  a  detach- 
ment of  the  vitreous  from  the  retina  equal  to  several  millometres  in  the 
region  of  the  postenor  pole.  It  seems  easy  to  attribute  this  to  the  sudden 
escape  of  aqueous  and  lens,  at  the  time  of  extraction.  This  detachment 
was  found  to  be  greatest  in  eyes  examined  soon  after  the  extraction.  If 
this  detachment  occurred  at  the  moment  of  extraction,  one  can  not  very 
well  understand  why  a  hemorrhage  did  not  occur  more  easily;  since,  how- 
ever, this  did  not  occur,  it  is  more  probable  that  the  detachment  resulted 
from  the  gradual  contraction  of  the  vitreous,  which  was  greatly  distended 
at  the  time  aqueous  and  lens  Avere  evacuated. 

A  great  deal  more  is  known  concerning  the  cause  of  detachment  of 
the  vitreous,  as  a  result  of  the  contraction  of  new  formed  cicatrical  tissue 
and  blood  vessels  wdiich  are  found  in  the  anterior  half  of  the  vitreous. 
Here,  again,  we  are  dealing  with  the  results  of  tlie  contraction  of  the 
infiltrated  vitreous,  subsequent  to  inflammatory  processes.^^ 

DETACHMENT  OF  THE  CILIARY  BODY.  This  likewise  is  due 
to  the  contraction  of  the  cychtic  bands,  which  extend  across  the  eye  from 
side  to  side  posterior  to  the  capsnle. 

DETACHMENT  OF  THE  RETINA.  It  has  been  abundantly 
proven  that  these  cychtic  bands  likewise  lead  to  detachment  of  the  retina.^^* 

GLAUCOMA. 

Cases  of  glaucoma  may  develop  immediately  after  a  cataract  extrac- 
tion, during  the  healing  of  the  operative  wound,  and  it  is  not  possible  in 
every  case  to  give  a  satisfactory  explanation  as  to  its  cause.  Rumsche- 
witsch  20  states  that  these  cases  are  not  as  rare  as  one  would  suppose,  and 
he  reports  three  cases,  in  one  of  which  the  lens  was  removed  in  its  cap- 

19  See  Iwanofe  Arch.  f.  Opth.,  XY.  2.  p.  59-60. 

19a  Erik  Nordenson.     Die  Netzliaut  ablosuns-     Wiesbaden,  1887. 

20  Zur  Casuistick  des  Glaucoma  nach  Staar  Operationen.  Zehender's  Monats- 
blatter,  June,  1896. 


354 

sule.     H.  Pagen steelier  21  states  that  this  eonditioii  usually  follows  in  the 

first  few  days,  subsequent  to  the  use  of  atropine;  henee  great  care  in  the 

use  of  this  mydriatic  is  indicated.     Such  eyes  may  never  have  shown  signs 

of  hypertonia,  but  fyequevlUj   in   eijes   irhirli    hare   hod   foniier   aftacls   of 

glaucoma. 

It  may  occur  in  eyes  which  up  to  the  third  or  fourth  week  have  shown 
no  sign  of  hypertonia.  Here  the  swelling  of  the  cortical  remains  may  be 
the  cause,  but  even  this  condition  has  been  shown  to  follow  when  the 
lens  has  been  extracted  in  its  capsule. 

As  we  have  seen,  as  long  ago  as  18G9  Von  Graefe  observed  cases  of 
acute  glaucoma  supervene  after  a  discission.  Here  the  swollen  lens  sub- 
stance pressed  the  iris  against  the  filtrating  angle,  thus  closing  it  off. 
Priestly  Smith  22  reports  the  case  of  a  child  in  which,  seven  years  subse- 
quent to  a  discission,  high  tension  developed.  This  was  found  to  be  due 
to  an  annular  synechia,  which  had  united  the  pupillary  margin  of  the 
iris  with  the  capsule,  locked  up  the  posterior  chamber,  and  thus  caused  a 
bulging  of  the  iris,  with  closure  of  the  filtrating  angle.  A  small  iridec- 
tomie  gave  exit  to  the  fluid  retained  behind  the  iris;  the  iris  retired,  from 
the  cornea;  the  eye  recovered  with  normal  tension.  He  shows  that  not 
infrequently  the  pupillary  margin  is  adherent  throughout  to  the  remains  of 
the  lens-periphery.  The  pupil  may  not  appear  to  be  blocked  by  any  visible 
false  membrane,  still  this  membrane  opposes  the  free  escape  of  fluid  from 
behind  the  iris.  Priestly  Smith  states  (page  59):  "High  tension  may  set 
in  3'ears  after  a  good  result.  JSTatason  (Uber  Glaucom  im  Aphaldschen 
Augen.  Mattieson.  Dorpat,  1889)  showed  that  immunity  from  subsequent 
glaucomatous  complication  is  not  insured  by  any  particular  operation. 
Glaucoma  may  occur  after  the  flap  operation  without  iridectomie,  after 
iridectomie  with  variously  placed  incisions,  after  an  extraction  preceded 
by  a  preliminary  iridectomie,  and  after  extraction  in  the  capsule.  They 
show  that  in  the  majority  of  cases  there  was  some  visible  complication 
involving  the  iris  or  the  capsule,  or  both,  namely,  iritis  or  irido-cycltis, 
with  occlusion  of  tlie  pupil,  prolapse  or  adhesion  of  the  iris  at  the  wound, 
or  a  similar  entanglement  of  the  capsule.  This  cicatrization  of  the  iris  or 
the  capsule  of  the  lens  in  the  wound  was  likewise  demonstrated  by  Stolt- 
ing23  aii(]  liosch.2'''a    In  some  cases,  on  the  other  hand,  the  eye  appeared 

21Gl:ni(oin   nncli    Staar   Extraction.     Zolipiidcr's   Klin.    Monatshlalter.    May, 
1895. 

22  The  ratiiolouy  and  Trcatiut'nt  of  (ilaucoma.  London.  1S!»1.  p.  57. 

23  Glaucom  nach  Linear  Extraction.     Graofe  Arcli..  Vol.  XXXIII.  B.  -2.  1SS7. 
23a(^lanconiatoso  nnd   .\troi)hisclio   Excavation   in   oincni   aphalviclicn   Anuc. 

Anil,  fur  An!,'('nh..  XXVIIT,  ;i."S.  ."ill. 


355 
to  be  quite  free  fi'oni  any  cuiniilicaiioii  of  the  kind.  -This  negative  evi- 
dence is,  however,  not  quite  conclusive,  for  slight  adhesions  of  the  kind 
in  question  may  he  quite  undiscoverable  in  the  living  eye,  and  that  they 
are  frequent,  even  in  satisfactory  cases,  has  been  proven  by  Becker.  Becker 
examined  wiili  the  inicrosfopo  thirty-eight  eyes  from  which  cataracts  had 
been  extracted,  and  in  only  oiif-tbird  of  these  was  the  iris  free  from  the 
scar,  although  thirty-two  of  the  thirty-eight  eyes  were  removed,  not  on 
account  of  any  trouble  during  life,  but  after  the  death  of  the  patient.  He 
expressly  slates  that  minute  adhesions  of  the  iris  or  capsule  may  be  quite 
invisible  in  the  living  eye. 

"It  is  obvious  that  an  entanglement  of  the  iris  or  the  lens  capsule  in 
the  wound  may  lead  to  a  closure  of  the  filtrating  angle  in  its  immediate 
neighborhood,  but  this  does  not  suffice  to  explain  the  occurrence  of  glau- 
coma. We  can  not  assume  that  obstniction  of  the  filtrating  angle,  confined 
to  a  small  part  of  the  circle,  is  sufficient  to  cause  high  tension;  on  the  con- 
trar}',  we  know  tliat  such  entanglements  after  cataract  extraction  are  com- 
mon, while  glaucoma  is  rare." 

"Treacher  Collins'  microscopical  examinations-*  give  more  positive 
evidence  as  to  the  cause  of  the  glaucoma.  In  nine  of  the  ten  eyes  exam- 
ined by  him  the  capsule  was  adherent  to  the  scar;  in  the  remaining  one 
from  which  the  lens  had  been  removed  in  its  capsule,  the  hyaloid  was 
adherent  in  the  same  manner.  The  filtrating  angle  was  closed  in  the 
neighborhood  of  the  scar  in  every  case;  moreover,  it  was  closed  at  the  oppo- 
site side  of  the  eye  also,  and  probably  throughout  the  whole  of  the  circle, 
in  seven  out  of  the  eight  cases;  and  in  those  in  which  it  was  not  closed 
by  apposition  of  the  iris  and  cornea,  it  was  blocked  by  exudation." 

"In  the  living  eye,  also,  we  can  sometimes,  I  think,  make  out  the 
cause  of  a  glaucomatous  complication  after  cataract  extraction.  In  some 
cases  the  iris  and  posterior  capsule,  being  united  and  coated  by  inflamma- 
tory exudation,  appear  to  form  an  impermeable  or  insufficiently  permeable 
diaphragm  across  the  eye,  which  checks  the  passage  of  fluid  from  the 
ciliary  processes  into  the  aqueous  chamber.  An  excess  of  fluid  becomes 
imprisoned  behind  this  diaphragm.  This  may  happen  although  a  good 
iridectomie  has  been  made.  In  a  case  of  this  kind,  on  the  eighth  day  after 
extraction,  and  in  the  presence  of  acute  iritis,  with  free  exudation  into 
the  aqueous  chamber  and  very  high  tension,  which  had  twice  rapidly  re- 
turned after  paracentesis  of  the  aqueous  chamber,  I  made  an  iridectomie 
downward,  tearing  completely  through  the  adhering  membranes,  and  ob- 


24  Trans,  of  Opth.  Society  of  the  United  Kiiiirdom.  Vol.  X.  p.  108. 


356 

taining  for  tlu'  nionu'iii  a  Jet  hlack  [)ii])il.     ''J'ho  L^yo  recovered  normal  ten- 
sion and  good  vision,  which  are  still  retained  after  thirteen  years." 

"It  is  not  eas3%  even  with  the  help  of  pathological  specimens,  to 
explain  the  occurrence  of  glaucoma  after  a  long  interval  of  time,  during 
which  the  eye  has  enjoyed  useful  vision.  It  appears  probable,  however, 
that  a  transparent  membrane,  stretching  across  from  the  ciliary  processes 
on  the  one  side  to  the  cicatrix  on  the  other,  may  in  course  of  time  undergo 
some  slight  contraction,  which  draws  the  processes  forward  so  as  to  com- 
press the  filtrating  angle.  Or  such  a  membrane  may  become  less  permeable 
than  at  first.  In  this  way,  or  perhaps  through  some  change  in  the  intra- 
ocular fluid  itself,  filtration  from  the  vitreous  to  the  aqueous  itself  is 
checked.  This  is  not  mere  conjecture.  In  an  elderly  lady  I  performed 
a  preliminary  iridectomie,  and  later  an  extraction,  apparently  with  com- 
plete success.  A  few  months  later  an  insidious  glaucoma  began,  which  at 
first  yielded  to  eserine,  but  later  became  persistent.  The  field  contracted, 
the  disc  became  cupped.  Sclerotomy  with  a  Graefe  knife  was  performed 
in  the  region  of  the  extraction  wound.  On  the  withdrawal  of  the  knife, 
hardly  any  fluid  escaped,  and  the  iris  applied  itself  closely  to  the  cornea, 
showing  that  fluid  was  imprisoned  behind  the  aqueous  chamber.  The 
point  of  the  knife  was  then  passed  in  again  through  the  same  wound,  and 
through  the  coloboma  into  the  vitreous.  A  gush  of  fluid  escaped,  the  iris 
retired  from  the  cornea  and  the  globe  became  slack.  The  eye  recovered 
with  normal  tension.  Curiously  enough,  I  operated  later  on  the  fellow 
eye  of  the  same  patient,  and  encountered  almost  exactly  the  same  sequence 
of  events.  In  some  cases  of  this  kind  the  high  tension  may  be  banished 
by  passing  a  cutting  needle  through  the  area  of  the  pupil,  so  as  to  divide 
the  ]josterior  capsule  and  the  anterior  of  the  vitreous.'' 

"With  regard  to  glaucoma  following  cataract  extraction,  we  can,  there- 
fore, assert  that  there  is  usually  a  closure  or  blockage  of  the  filtrating 
angle,  although  we  can  not  in  every  case  ascertain  the  precise  manner  of 
its  production.  The  ])oint  of  practical  importance  is,  that  such  an  ob- 
struction can  be  remedied  only  while  it  is  recent:  and  wlieii  the  base  oi 
the  iris  has  become  adherent  tlirouglioiit  to  the  uoriphery  of  the  cornea, 
the  glaucoma  is  incurable." 

The  warning  can  not  be  stated  too  emphatically  to  beware  of  matur- 
ing posterior  cortical  cataracts,  and  then  extracting,  without  first  investi- 
gating as  to  tlic  [)robal)le  cause  of  tliis  couditiou.  'i'lu'sc  cases  are  always 
secondai'v  to  disease  of  tin-  uveal  tract,  and  the  i)ossil)iliiy  of  a  secoud  at- 
tack of  glaucouia  sul)se(|Ui'nl  to  exti'aeliou  should   nol   he  forgotteu. 

Fiually,  I  he  fact  can  not  eutii-ely  he  sel  aside,  llial  the  arthritic  or 
goutv  diathesis  may  he  Hie  pi'luu'  causative  factor  in  ihe  |iro(lu(iiou  of  glau- 


357 

coma  in  an  apliakic  fvi\  \\1iieli  in  tliis  case  is  inih'pcndcnt  of  any  patlio- 
logical  clian.i^cs  atlrihulahlc  Id  the  opci-aiion.  Di-.  David  Dcr'x-ck  lias  re- 
cently illustiMtcd  tlu'sc  facts  by  xmic  xcry  iii-t  riictivi'  cax-  rcjxtrts.  (Tlio 
Ohio  Medical  .luunial.  \'..l.  IX.  X..s.    1  and  !i.  ISIKS.) 

CHAPTER  IV. 

Paradoxical  as  it  may  seem,  the  after  treatment  beo^ins  before  the 
operation,  and  is  not  finished  when  the  patient  is  dismissed  from  the  hos- 
pital or  the  personal  care  of  the  physician. 

THE  MATFEATION  OF  CATARACT.     TTIK  ATrriFTCTAL  h'JPEX- 
IXG  OF  CATARACT. 

Formerly  months  and  even  years  were  required  before  a  cataract  was 
considered  as  operable.  Owing  to  a  large  c^nantity  of  cortical  substance 
which  remains  behind  when  a  cataract  is  operated  before  it  is  ripe,  and 
the  detrimental  influence  which  a  large  quantity  of  cortex  may  cause,  oper- 
ators have  always  been  fearful  of  extracting  an  unripe  cataract.  One  can 
only  understand  what  a  ripe  cataract  is  where  we  take  into  consideration 
how  it  has  develojaed. 

Celseus  was  the  first  to  give  a  more  exact  description.  "One  must 
wait  (before  operating)  for  a  kind  of  ripening  of  tlie  cataract  (maturitas), 
until  it  is  no  longer  fluid,  but  has  rather  acquired  a  certain  hardness  as  a 
result  of  coagulation."  According  to  Beer,^  a  grey  cataract  is  ripe  when 
it  is  not  possible  for  it  to  undergo  further  development.  The  expression 
"ripe  cataract"  has  been  handed  down  to  us;  but  our  understanding  of  the 
pathological  changes  has  been  radically  changed,  and  has  been  fully  con- 
sidered in  the  second  part  of  this  work. 

It  certainly  does  not  appear  wise  nor  humane  to  cause  a  person  af- 
flicted with  cataract  to  pass  an  indefinite  period,  waiting  for  the  cataract 
to  reach  maturity.  Where  there  is  disease  of  the  one  eye,  the  other  still 
having  good  vision,  we  may  leave  it  to  the  discretion  of  the  patient,  as  to 
whether  he  will  undergo  an  operation  or  not.  But  where  the  other  eye  is 
also  affected,  and  the  patient  can  no  longer  follow  his  vocation,  it  certainly 
seems  no  more  than  proper  that  we  should  do  all  in  our  power  to  both 
assist  him  in  regaining  his  sight  and  luisten  the  i-ipening  of  the  cataract. 
We  certainly  would  err  greatly  if  we  would  permit  those  advanced  in  years 
to  pass  the  few  remaining  years  of  their  life  in  the  useless  waiting  for  a 
cataract  to  ripen,  simply  because  the  ancients  imagined  that  cataract  was 
an  excretion,  or  to  wait  for  the  cataract  to  harden. 

At  the  present  day  we  know  that  a  ripe  cataract  can  easily  be  ex- 

1  Ansonkrankheiton  II.  ."110.    Wien..  1S17. 


358 

tracted  from  its  capsule.     Professor  Schweigger  -  does  not  believe  that  it 
is  necessary  to  cause  an  artificial  ripening,  after  the  time  when  physiolog- 
ical changes  in  the  lens  have  done  away  with  the  act  of  accommodation; 
that  is,  toward  the  fifties  and  surely  after  the  sixtieth  year.     He  beheves 
that  every  cataract  may  be  extracted  as  soon  as  the  interference  of  sight 
demands  the  operation,  even  if  the  greater  portion  of  the  lens  is  still  clear. 
"An  equal  degree  of  cloudiness  in  a  young  individual  would  designate 
an  unripe  cataract.    In  a  young  individual,  accommodation  is  still  present, 
the  cortex  of  the  lens  still  consists  of  a  tenacious  sticking  mass,  which  ad- 
heres to  the  capsule,  and  if  now  such. a  lens  extraction  is  made  the  nucleus 
still  escapes,  but  the  cortex  remains  behind  adherent  to  the  capsule.  Though 
the  pupil  appear  black  in  the  beginning,  it  will  soon  become  cloudy,  owing 
to  the  saturation  with  aqueous;  the  changes  here  are  simply  those  following 
discission.     Generally  speaking,  after  the  fortieth  year,  every  human  lens 
contains  a  hard  nucleus.     If  the  corneal  wound  is  of  sufficient  size,  and 
the  capsule  is  properly  opened,  the  cataract  can  be  delivered  on  the  slight- 
est pressure,  and  it  is  immaterial  whether  it  is  ripe,  partially  ripe,  entirely 
ripe,  or  over-ripe.     Alfred  von  Graefe  ^  certainly  did  a  great  thing  when 
he  declared  operable  the  brown,  posterior  cortical,  and  the  punctate  stri- 
ated cataract."  Schweigger  declares  that  for  some  years  past  he  has  handled 
the   subject  in  a  purely  practical  manner.  He    operates  all  patients   past 
the  fiftieth  year  as  soon  as  the  senile  cataract  interferes  greatly  with  the 
patient's  vision,  "so  that  life  ceases  to  be  a  pleasure  to  him,  and  he  becomes 
unable  to  be  self-sustaining,  and. the  doctor  may  hope  that  by  the  removal 
of  the  lens  \dsion  may  be  materially  improved.     It  is  immaterial  whether 
a  greater  or  less  portion  of  the  lens  is  still  clear." 

Schweigger  seems  to  believe  that  all  methods  of  artificial  ripening  of 
hard  cataract,  which  have  as  their  object  the  shortening  of  the  time  of 
blindness,  can  be  dispensed  with.     He  considers  them  purposeless. 

He  states:  "To  my  mind  it  is  antiquated  to  teach  the  practicing  phy- 
sician how  to  diagnose  a  ripe  cataract.  It  is  useless  to  make  four  operations 
on  one  eye.  (1)  The  preparatory  iridectomie;  (3)  The  trituration;  (3)  The 
extraction  through  a  small  opening;  (4)  A  subsequent  secondary  operation. 
By  a  single  operation  we  not  only  reach  the  same  end.  but  do  it  more 
quickly  and  better." 

It  had  been  observed  long  since,  that  where  the  capsule  of  the  lens 
was  accidentally  touched;  during  an  operation  either  on  the  iris  or  opening 
of  the  anterior  chamber,  that  a  subsequent  cloudiness  of  the  lens  followed. 


2  The    Extraction  of    Unripe    Cataract,    Berlin  Med.  Society,    July  2,  1890, 
Hirschberg's  Centralblatt,  p.  206. 

3  A.  f.  O.,  XXX,  4,  22.5.    1884. 


359 

It  was  supposed  tliat  here  tlie  .onlmt  In'twcrn  the  instruinonl  and  the 
capsule  of  the  lens  caused  a  disturbance,,  either  in  the  epithelial  cells  lin- 
ing the  capsule,  or  a  dislocation  of  the  fibres  innnrdiatoly  beneath  the  epi- 
thelial cell;  as  a  consequence,  interference  with  ihe  proper  .  utrition  and 
the  regular  arrangement  of  the  lens  filn-es  followed,  with  the  further  result 
of  cataract  formation.  Foerster  believed  that  there  was  a  mechanical  de- 
struction of  the  lamellae  between  capsule  and  nucleus,  and  to  him  is  due' 
the  credit  of  having  first  utilized  this  fact  in  hastening  the  ripening  of 
cataract.  He  originally  made  the  preparatory  iridectomie,  and  then  gently 
massaged  the  external  corneal  surface  by  means  of  a  strabismus  hook,  and 
in  the  course  of  four  to  eight  weeks  the  cataract  wf.s  ready  for  extractidn. 
The  difficulty  in  doing  this  operation  has  always  depended  on  estimating 
the  requisite  amount  of  pressure  to  be  applied;  since  if  this  be  excessive 
the  zonula  is  easily  ruptured,  and  with  the  result  o^  loss  of  vitreous  at  the 
time  of  the  extraction.  This  method  of  ripening  has  been  widely  em- 
ployed. Some  bolder  operators  of  the  present  day  even  entering  the  an- 
terior chamber  with  a  small  spatula,  and  triturating  the  lens  direct. 

The  artificial  ripening  of  cataract  has  been  the  subject  of  considerable 


experimental  investigation  by  Hellferich,*  Oettinger 


5  and  finally  by  Schir- 
mer.6  Schirmer  experimented  on  fifty-two  rahbits  in  exactly  the  same 
manner  as  Foerster  did,  Avithout,  however,  making  an  iridectomie.  He 
found  that  the  earliest  cloudiness  set  in  in  one  or  two  hours  after  tritu- 
ration, which  could  be  defined  as  a  series  of  very  fine  striations  on  focal 
illumination.  In  the  course  of  a  few  hours  this  had  advanced  toward  the 
equator  until  a  circumference  of  this  cloudy  area  about  the  size  of  a  moder- 
ately dilated  pupil.  In  forty-six  cases  a  decided  cloudiness  followed;  in  ten 
a  total  cataract.  On  microscopical  examination  he  found  that  as  the  result 
of  mechanical  pressure  of  the  strabismus  hook,  the  capsular  epithelial  cells 
undoubtedly  degenerate.  The  nuclei  of  the  cells  show  considerable  re- 
sistance, with  at  first  formation  of  vacuoles,  until  finally  these  were  pressed 
out  of  the  shrinking  chromatin  net-work,  which  forms  a  l)iMght  halo 
around  them.    The  chromatin  finally  splits  up  in  fine  granules. 

Immediately  after  the  operation  the  superficial  fibres  are  separated 
from  each  other,  and  spindle-shaped  interspaces  are  formed.  These  spaces 
soon  increase  and  are  filled  with  granular  substance.  The  fibres  of  the 
superficial  layers  swell  up  into  vesicles,  burst,  and  their  contents  exude 
under  the  capsule      This  disintegration  is  undoubtedly  hastened  by  the 

4  Uber  kunstliclie  reifung  des  staare.    Sitzungs  Berlchte  dor  Wurtzburger 
Phys,  Med.  Gellschaft.  1884.  p.  115. 

5  Uber  kunstliclie  reifung  des  staares.    Inaugural  Dissertation.  Breslau.  1885. 

6  Experimentelle  Studie  uber  die  Forstersche  Maturation  der  Cataract.    Von 
Dr.  Otto  Schirmer  Graefe.  Vol.  XXXIV.  B.  1,  180.3. 


36o 

entrance  of  acjueous^  into  the  capsular  sac.  As  a  result  of  this  disintegra- 
tion of  lens  fibres,  the  processes  of  diffusion  set  in  between  the  lens  and 
humor  aqueous,  just  as  in  other  forms  of  cataract,  and  since  the  fibres 
possess  a  different  coefficient  of  refraction,  this  zone  becomes  non- 
transparent  to  rays  of  light,  and  hence  will  appear  white.  But  if  the  fibres 
disintegrate,  and  a  more  homogenous  mass  is  formed,  the  substance  may 
be  carried  out  of  the  capsule  to  such  an  extent  as  to  cause  small  indenta- 
tions on  the  surface  of  the  anterior  capsule.  ;Meanwhile,  the  lens  con- 
tinues to  grow  at  the  equator,  and  the  new  fibres  extend  immediately  be- 
neath the  epithelium  toward  the  pole,  so  that  the  entire  detritus  may  be 
surrounded  by  new  formed  lens  fibres. 

In  ever}^  case  where  we  expect  a  successful  maturation  the  massage 
must  be  exerted  to  an  'i-qual  degree  on  all  fibres,  in  order  that  we  may  ju-o- 
duce  an  equal  destruction,  and  thus  lead  to  a  total  cataract.  The  fibres 
can  only  be  destroyed  where  the  tension  within  the  capsule  is  increased. 
"This  pressure  causes  a  dislocation  of  the  various  lamellae,  and  the  for- 
mation of  interspaces  in  which  fluid  stagnates,  thus  setting  up  an  abnor- 
mal process  of  diffusion  and  a  subsequent  disintegration  of  the  lens  fibres." 

THE  AFTER  TREATMENT. 

Sufficient  has  already  been  said  concerning  the  preparatory  treatment. 
If  necessary  the  patient's  general  health  should  be  cared  for,  examination 
of  the  lungs,  the  presence  of  an  aggravated  bronchitis,  should  be  allevi- 
ated as  much  as  possible,  in  order  to  prevent  coughing  spells  during  the 
time  the  patient  must  be  quietly  on  the  back,  and  the  urine  should  always 
be  examined,  and  finally,  the  bowels  should  always  be  thorcnighly  evacu- 
ated before  the  operation.  The  conjunctiva  should  b^  thoroughly  cleansed 
with  antiseptic  solutions  before  the  operation. 

At  the  present  day  neither  atropine  nor  eserine  are  used  previous  to 
an  operation.  Becker,  however,  gives  us  special  indications  for  their  use, 
which  are  likewise  applicable  today.  He  tells  us.  "In  i)erforming  the  flap 
operation  the  right  eye  was  brought  fully  under  the  influence  of  atropine. 
The  idea  being  to  lessen  the  chances  of  the  iris  eoming  in  contact  with 
the  knife,  and  at  the  siune  time  facilitating  the  exit  of  t  he  lens."  We  believe 
the  observation  is  correct,  for  though  tlu'  itupil  conliMcls  the  nioiuent  the 
aqueous  is  evacuated,  the  iris  is  more  t'asily  dilated  by  the  h'us  after  open- 
ing the  capsule  of  the  lens,  when  tlie  eye  has  been  previ(.u>ly  atropized. 
For  the  time  being,  the  action  of  the  atropint'  is  overeonu'  by  the  induced 
spastic  contraction  of  the  sphincter,  without  this  action  being  of  a  lasting 
character.     In  the  course  of  a  normal  healing,  one  will  lind  that  the  im[)il 


\ 


361 

which  at  the  time  of  tlie  operation  was  t-ontracted.  will  in  the  conrse  of  a 
few  hours  become  fully  dilated  again. 

Likewise,  in  the  beginning  atropine  was  used  in  the  Graefe  operation. 
Eduard  :Nreyer,  however,  suggested  that  its  use  previous  to  the  operation 
be  abandoned,  and  this  suggestion  has  found  general  favor.  The  belief 
was  expressed  that  cicatrization  of  the  iris  could  be  avoided  in  many  cases, 
since,  if  we  did  not  paralyze  the  sphincter  previous  to  the  operation,  the 
iris  Avould  contract  after  the  escape  of  aqueous,  and  thus  permit  the  iris 
from  becoming  involved  in  the  wound." 

For  the  same  reason  DeWecker,  in  making  his  operation  without  ex- 
cision of  a  piece  of  the  iris,  goes  a  step  further,  in  that,  at  the  conclusion 
of  the  operation,  he  drops  a  drop  of  sulphate  of  eserine  (|  per  cent,  so- 
lution) into  the  eye,  and  thus  by  contraction  of  the  pupil  draws  the  iris 
out  of  the  wound.    Instead  of  a  mydriatic  he  uses  a  myotic. 

It  is  a  matter  of  special  importance  to  carefully  examine  and  watch 
the  conjunctiva  before  the  operation.  A  host  of  observers  have  shown  us 
the  effect  of  an  infected  lachrymal  secretion.  The  deleterious  effects  of  a 
tear  sac  blenorrhoea  have  been  recognized  for  a  long  time;  and  one  would 
hardly  expect  to  find  an  operator  at  the  present  day  who  would  perform 
an  operation  without  first  healing  the  latter  condition. 

The  same  is  true,  though  to  a  lesser  degree,  of  all  forms  of  conjunc- 
tival disease.  A  chronic  catarrh  should  be  suppressed  as  much  as  possible, 
and  one  should  not  forget  that  after  an  operation,  owing  to  pressure  of  a 
bandage,  the  secretion  may  rapidly  increase  again.  This  should  diligently 
be  watched,  the  conjunctival  sac  kept  clean,  and  thus  the  accumulation 
of  the  secretion  prevented. 

It  is  a  peculiar  tiroumstance  that  trachoma,  granular  conjunctivitis  (chronic 
blenorrhoea  of  Arlt.  opthal  aegyptica),  is  not  to  be  looked  upon  as  a  contra- 
indication to  the  performance  of  an  extraction.  At  least  this  is  true  where 
pannus  has  developed,  for  the  vessels  in  the  cornea  lead  to  a  rapid  and  fortu- 
nate healing  of  the  corneal  wound. 

THE  AFTEE  TREATMENT.  Von  Graefe  Avarned  us  against  a  cer- 
tain indifference  which  even  men  of  the  greatest  ability  have  been  guilty 
of,  as  soon  as  the  process  of  healing  takes  an  anomalous  course.  He  says: 
"True,  owing  to  inability  to  explain  in  every  case  the  cause  of  the  intense 
reaction,  one  easily  falls  into  the  fatal  error  of  simply  laying  one's  hand  in 
one's  lap  just  as  soon  as  the  pain,  active  secretion,  redness  and  swelling 
of  the  conjunctiva,  uncleanness  of  the  wound,  cloudiness  of  the  cornea, 
hypopyon,  or  hemorrhage  into  the  anterior  chamber  set  in.  True,  at  the 
suggestion  of  a  more  experienced  colleague,  one  tries  oiu^  thing  then 
another,  but  since  n<.  one  method  seems  to  avail  in  a-ll  cases  which  present 


362 

ilie  same  symptoms,  we  become  dissatislied.  and  at  times  desist  from  any 
further  attempts.  Thus  we  turn  from  one  mode  of  treatment  to  another, 
and  finally  we  become  completely  skeptical,  since  no  form  of  treatment  is 
uniforndy  followed  by  favorable  results." 

This  was  written  before  the  study  of  bacteriology  had  assumed  its 
present  important  position,  and  1)efore  the  full  extent  of  the  action  of 
micro-organisms,  in  the  production  of  inflammation  was  recognized.  Today 
we  know  that  all  pathogenic  germs  may  and  do  lead  to  destruction  of 
the  eye.  Prevention  of  an  infection  is  the  watchword,  for  after  the  in- 
terior of  the  eye  is  once  invaded,  we  may  as  well  stand  by,  for  we  are 
helpless  to  stay  the  inflammation.  All  we  can  do  is  to  alleviate  the  pain, 
meet  complications  as  they  arise,  and  eventually  enucleate  to  prevent  in- 
fection of  the  other  eye. 

The  first  symptom  which  demands  attention  is  pain.  Since  the  nor- 
mal course  of  healing  is  accompanied  by  pain,  it  would  certainly  seem  im- 
portant to  fix  a  border  line  where  this  becomes  pathological.  This,  how- 
ever, is  impossible,  since  some  patients  are  more  sensitive  than  others. 
This  pain  is  usually  described  as  a  burning  pain.  This  never  increases,  but 
usually  continues  during  the  first  few  hours,  gradually  growing  less.  After 
five  or  six  hours  there  should  no  longer  be  a  continuous  pain.  From  time 
to  time  the  patient  experiences  a  slight  sensation  of  pressure.  This  is 
followed  by  a  short,  pricking  sensation,  followed  by  a  sensation  as  though 
something  were  flowing  from  the  eye.  This  sensation  is  due  either  to  the 
accumulation  of  tears  in  the  conjunctival  sac,  which  in  cases  where  the 
margins  of  the  lids  have  become  agglutinated  together,  can  only  escape 
when  the  pressure  of  the  accumulated  tears  forces  the  Ms  apart.  Or  the 
pressure  and  the  pricking  pains  are  due  to  the  accumulated  aqueous  forcing 
the  edges  apart,  and  thus  escaping,  either  beneath  conjunctiva  or  into  the 
conjunctival  sac,  and  then  finally  escaping,  between  the  edges  of  the  lids. 

These  sensations  can  not  be  included  with  those  of  active  reaction. 
As  soon  as  the  pain  becomes  paroxysmal,  or  changed  from  a  burning  to  a 
tearing,  lancinating,  boring  or  thumping,  it  is  to  be  alleviated  by  any 
method  possible. 

The  bandage  should  be  removed,  the  wound  carefully  t'xamined  and 
carefully  cleansed.  If  the  pain  continues,  cold  applications  and  a  hypo- 
dermic injection  of  morphia  are  indicated.  Under  all  circumstances  the 
patient  should  have  a  good  night's  rest.  If  necessary  bromide  of  potash 
and  chloral  are  indicated. 

In  normal  cases,  all  signs  of  wound  reaction  disapjioar  l)otween  twelve 
and  twenty-four  hours.  Becker  warns  us  that  the  very  worst  forms  of 
disease  begin  to  manifest  themselves  toward  the  close  of  the  first  night. 
The  bandage  should  at  once  be  removed  and  the  wound  oxaniinod.  and  if 


363 
there  is  no  tearing  or  swelling  of  tlie  li(i.s,  the  simple  application  of  a 
fresli  dressing,  together  with  the  usual  washing  off  of  the  edges  of  the 
lid,  will  he  sufficient.  If,  however,  the  linen  paa  which  covers  the  eye 
is  wet  and  covered  with  purulent  secretion,  we  know  that  we  are  dealing 
with  an  infection.  Von  Graefe  advised,  after  carefully  cleansing  the  lids, 
that  we  touch  the  entire  surface  with  nitrate  of  silver  and  then  thoroughly 
neutralize  the  same.  In  rohust  individuals  he  even  practiced  venesection. 
Today  use  of  antiseptics  is  called  for.  and  as  has  already  been  stated,  many 
operators  cauterize  the  edges  of  the  wound;  and  the  anterior  chamber  is 
wa><hed  out  with  an  antiseptic  solution.  If  this  does  not  stay  the  inflam- 
matorv  process  the  eye  is  lost. 

MENTAL  DERANGEMEXTS  AFTER  CATAEACT  EXTRAC- 
TIONS. It  is  customary  to  bind  up  both  eyes  during  the  first  four  or 
five  days  subsequent  to  an  extraction,  and  during  thi<  time  acute  delirium 
has  been  known  to  develop.  While  in  this  state  patients  tear  the  bandages 
from  their  eyes,  and  thus  forever  destroy  the  results  of  what  might  other- 
wise have  been  a  successful  operation.  Cases  are  recorded  in  which  the 
wildest  mania  developed,  and  in  which  it  ^vas  impossible  to  restrain  the 
patient.  Parinaud  and  Sichel  believed  this  to  be  a  cerebral  disturbance, 
due  to  the  removal  of  light  and  the  restricted  diet  subsequent  to  the  oper- 
ation. Grandelement,  Galezowski,  Salvator,  Angela  Ledda,  as  due  to  use 
of  atropine,  Chibret  to  alcoholism;  whereas  Borreli  beheved  this  to  be  due 
to  a  predisposition  to  mania.  Swanzy  believes  that  it  is  due  to  the  quiet 
and  exclusion  of  light,  following  a  period  of  some  anxiety  and  excitement. 
He  believes  that  permission  to  sit  up  in  bed,  with  the  admission  of  some 
light,  will  speedily  restore  the  mental  equilibrium.  Therapeutically,  sul- 
phonal,  chloral  and  the  bromides  are  useful. 

Patients  should  never  be  left  alone,  even  during  the  night.  They  may 
unconsciously  disarrange  the  dressing,  and  thus  infect  the  wound.  In  rest- 
less patients,  it  is  even  advisable  to  tie  the  hands,  ^Many  a  successful  oper- 
ation has  been  brought  to  naught  by  the  patient  sticking  his  hand  or 
fingers  against  the  bandage  with  sufficient  force  to  rupture  the  wound, 
which  has  closed  leading  to  prolapse  of  iris  or  vitreous,  even  to  an  intra- 
ocular hemorrhage.  Many  operators  today  have  the  nurse  tie  the  patient's 
hands  at  night,  or  an  electric  bell  is  within  reach,  so  that  the  nurse  may 
be  called  at  any  moment. 

DISCHARGE  OF  THE  PATIENT  FROM  THE  PHVSICIAX'S 
CARE.  It  is  certainly  not  only  a  matter  of  interest  to  the  patient  who 
longs  to  return  home,  but  also  to  the  physician  who  may  desire  (in  hos- 
pital practice)  the  bed  for  other  patients,  that  the  patient  be  not  detained 
a  single  day  longer  than  is  absolutely  necessary.     Alreadv  Beer  stated  that 


3^4 

the  average  time  tor  a  normal  healing  was  about  fifteen  days.  Later  oper- 
ators placed  this  time,  including  cases  in  which  the  processes  of  healing 
was  not  perfectly  regular,  at  three  weeks. 

It  is  certainly  not  without  interest  to  note  that  Gussenhauer  fixed  the 
time  of  a  normal  healing  after  an  extraction  at  seventeen  days;  that  is, 
that  a  total  restoration  of  the  connection  between  the  divided  corneal 
fibres  was  established  in  that  time.  Hence  we  must  assume  that  the  injury 
to  other  structures,  iris,  capsule,  etc.,  does  not  in  any  way  interfere  with 
the  timely  healing  of  the  cornea.  But  it  is  quite  a  different  matter  as  to 
how  soon,  in  the  individual  case,  a  patient  can  be  discharged  and  released 
from  the  observation  of  the  physician.  It  is  customary  to  be  guided  by  the 
condition  of  the  conjunctiva  bulbae.  On  the  one  hand,  we  meet  with 
cases  in  which  this  does  not  become  injected;  whereas,  on  the  other  this 
injection  may  simply  be  the  result  of  a  conjunctival  catarrh,  without  a 
more  serious  cause.  But  Just  for  this  first  class  it  is  of  great  importance 
to  be  able  to  fix  the  time  of  observation,  since,  according  to  Gussenbauer's 
anatomical  investigations,  it  would  be  wrong,  even  in  the  most  favorable 
case,  to  let  a  patient  go  before  tlifi  beginning  of  the  third  week. 

True,  patients  have  left  the  clinic  as  early  as  th-e- sixth  and  eighth 
day,  without  suffering  the  slightest  detriment  from  this  cause.  Others, 
again,  released  on  the  twentieth  day,  returned  a  short  time  afterward, 
either  with  a  corneal  infiltration,  hemorrhage  into  the  anterior  chamber, 
iritis  or  irido-cyclitis.  Hence,  it  seems  but  proper  that  the  patient  should 
be  kept  under  observation  as  long  as  possible,  even  though  the  process  of 
healing  has  been  a  nonnal  one.  For  where  is  the  operator  who  will  be 
willing  to  assert  in  any  special  case  that  the  pathological  changes  which 
have  been  started  in  the  iris  and  capsule  have  entirely  ceased? 

A  still  more  fatal  error  is  to  permit  the  patient  to  begin  the  use  of 
his  glasses  too  soon.  Though  it  is  true,  that  owing  to  the  loss  of  the  lens, 
the  eye  has  lost  its  power  of  accommodation,  still  we  must  not  assume, 
that  the  ciliary  muscle  does  not  contract  when  an  effort  is  made  to  ac- 
commodate, especially  in  cases  in  which  the  other  eye  still  performs  its 
functions,  and  the  attem))t  is  made  to  see  objects  near  by.  As  a  result  of 
every  such  accommodative  effort,  a  certain  traction  on  and  displacement 
of  the  zonula  fibres  follows.  As  long  as  the  processes  of  proliferation  are 
still  going  on  in  the  secondary  cataract,  even  in  the  simple  secondary 
cataracts,  these  apparently  unimportant  movements  uiay  be  sufficient  to 
reawaken  these  processes  of  new  formation,  and  thus  lead  to  a  greater 
thickness  and  density  of  the  secondary  cataract.  But  if  this  secondary 
cataract  has  already  closed,  it  will  then  depend  entirely  on  the  extent  of 
the  cicatrization,  and  the  structures  which  have  taken  part  in  its  formation. 


365 
what  the  cliaracter  of  the  induced  se(|iielae  will  be  We  have  already  >een 
how  the  shrinkage  of  the  complicated  secondary  cataract  may  become  the 
cause  of  long-continued  signs  of  irritation  on  the  operated  eye,  and  how 
this  condition  may  induce  sympathetic  irritation;  so  likewise,  the  early  use 
of  cataract  glasses,  owing  to  their  inducing  efforts  at  accommodation  in  the 
opei-ated  eye,  are  only  too  often  the  indirect  cause  of  iritis  and  cyclitic  irrita- 
tion wliich  develops  later  on.  Many  a  case  of  cicatrization  of  the  iris  and 
ca])sul('.  which  would  not  have  given  rise  to  any  trjuble,  take  a  fatal  ter- 
mination as  the  result  of  the  early  use  of  glasses. 

It  is  not  an  easy  matter  to  make  a  general  statement  as  to  tlie  time 
after  which  the  use  of  glasses  can  no  longer  be  looked  upon  as  detrimental. 
This  depends  on  the  mode  of  healing.  The  older  physicians  were  correct 
when  they  laid  down  the  rule  that  cataract  glasses  should  not  be  used 
until  months  after  an  extraction. 

THE  SECONDx\KY  OPERATIONS.  In  the  broad  sense  of  the 
term,  these  ought  to  be  considered  a  part  of  the  after  treatment,  since 
both  the  simple  and  complicated  secondary  cataracts  may  give  rise  to 
occasion  for  practicing  these  secondary  operations.  Whether  the  amount 
of  vision  obtained  after  a  cataract  operation  will  be  sufficiem  or  not  does 
not  alone  depend  on  the  degree  of  vision  attained,  but  also  on  the  demands 
which  the  patient  makes  on  his  eye.  A  farmer  or  a  day  laborer  will  be 
well  satisfied  if  he  can  read  medium-sized  print;  whereas,  one  who  follows 
intellectual  pursuits  will  require  more  vision,  and  request  a  secondary  oper- 
ation. 

Since  a  secondary  cataract  may  also  result  from  injuries  of  the  lens 
system,  and  since  the  difference  between  secondary  cataract  subsequent  to 
an  operation  for  cataract  and  traumatic  cataract  is  really  only  one  of  de- 
gree, hence  the  treatment  of  both  will  be  considered  together. 

The  therapy  of  injuries  of  the  lens,  and  of  traumatic  cataract,  as  well 
as  the  prognosis  of  these  injuries,  and  the  character  of  operation  to  be 
made,  depends  entirely  on  which  other  portions  of  the  eye  were  injured, 
and  what  the  condition  of  the  eye  is  after  the  injury  has  healed. 

TREATMENT  0¥  RECENT  INJURIES.  Traumatic  cataracts,  in 
which  there  has  been  no  injury  other  than  of  the  capsule,  do  not  re(}uire, 
during  the  period  of  their  formation,  any  other  treatnuMit  than  tliat  which 
any  other  disease  process  present  at  the  time  may  require.  Use  of  atropine 
prevents  iritis  and  breaks  up  any  possible  synechia  already  present.  It  is 
dependent  on  other  circumstances  whether  the  cataract  will  remain  partial 
or  become  complete. 

If  only  the  capsule  of  the  lens  has  been  involved,  and  no  foicign  body 
has  remained  in  the  lens,  which  is  only  possible  where  the  wound  in  the 


366 

capsule  is  a  small  one,  the  pupil  is  to  be  widely  dilated  by  atropine,  and 
then  await  developments  and  see  whether  the  wound  in  the  capsule  heals, 
or  if  the  tumescent  lens  substance  is  extruded  into  the  anterior  chamber. 
If  the  corneal  wound  heals,  and  no  signs  of  a  violent  reaction  develop 
during  the  lirst  few  days,  which  may  result  from  the  most  trivial  solutions 
of  continuity,  owing  to  increased  tension  in  the  eye,  the  same  regulations 
are  to  be  followed  as  in  cases  of  discission.  Simultaneous  injury  of  the 
iris  will  not  call  for  any  special  therapeutic  procedure.  Often  the  involve- 
ment of  the  iris  is  the  cause  of  a  more  rapid  healing  of  the  wound  in  the 
capsule.  Under  certain  circumstances  a  cut  in  the  sphincter  of  the  iris 
may  assume  the  role  of  a  prophylactic  iridectomie. 

One  of  the  evil  results  of  the  above  conditions  may  be  a  swelling  up 
of  the  lens  substance.  As  a  result  of  his  painstaking  observations  of  trau- 
matic discissions,  A'on  Graefe  restricted  the  indications  for  discission  to 
the  young.  This  swelling  lens  substance  may  lead  to  secondary  glaucoma 
in  the  aged,  and  at  times  even  in  the  young.  In  younger  eyes  the  elasticity 
of  the  outer  coats  is  greater;  hence,  a  passing  intra-ocular  tension  is  more 
easily  borne,  until  finally  disturbance  in  the  circulation  sets  in,  and  per- 
manent increase  of  tension  ^ets  in.  Hence,  in  the  aged,  owing  to  the 
greater  rigidity  of  its  walls,  glaucoma  and  excavation  of  the  papilla  set  in 
much  sooner,  the  conditions  being  the  same.  Kot  infrequently  we  see  the 
eyes  of  children  under  the  influence  of  traumatic  cataract  for  weeks  and 
months,  and  in  a  condition  of  increased  intra-ocular  tension,  without  the 
optic  nerve  suffering  in  any  way.  Whereas,  in  old  people  we  find  the 
most  insignificant  swelling  of  isolated  pieces  of  lens  substance  lead  to  glau- 
coma. This  has  been  shown  to  be  due  to  pressure  on  the  root  of  the  iris. 
This  presses  against  the  filtrating  angle  in  the  anterior  chamber,  and  thus 
excluding  a  part  of  the  filtrating  angle,  leads  to  interference  with  the  out- 
flow of  fluid,  and  thus  causes  glaucoma. 

If  it  is  evident  that  glaucoma  is  about  to  set  in,  or  if  it  is  ali-eady 
present,  one  should  not  delay.  The  pressure  phosphenes  are  especially 
valuable  in  testing  the  field  of  vision,  since  the  tumescent  lens  substance 
materially  afi'ects,  owing  to  the  diffusion  of  liglit,  all  tests  for  projection. 
The  indications  seem  to  he  divided  between  simi)le  iridectomie,  cataract 
extraction,  or  a  combination  of  both  methods,  t,)  young  children  one 
would  make  an  extraction  of  tlic  lens  by  a  simple  linear  extraction,  or  by 
modified  extraction  in  use  today.  If  violent  synij)toms  hav(>  developed, 
and  call  for  interference,  the  lens  will  always  be  found  to  hv  so  intensely 
swollen  as  to  escape  at  once  on  making  the  incision.  If  the  individual 
is  older,  and  the  increased  intra-ocular  tension  is  due  to  but  slight  swelling 
which  is  pi-essing  on  the  posterior  surface  of  the  iris,  the  entire  lens  not 


being  swollen,  a  simple  iridectomie  at  tlio  ])lac-('  where  the  pressure  is  ex- 
erted, would  give  by  far  the  best  results,  and  if  necessary  one  would  later 
on  make  a  much  better  cataract  extraction.  If  the  patient  is  past  the  years 
of  adolescence,  and  the  lens  is  swelling,  one  will  find  the  greatest  relief 
follow  a  linear  incision. 

In  the  above  described  cases  it  frecjucntly  happens  that  the  injury  to 
the  lens  is  the  smallest  part  of  the  injury  to  the  eye.  This  is  always  the 
case  when  the  corpus  ciliare  is  injured,  be  this  ever  so  slight.  The  fatal 
influence  which  a  shrinking  cicatrix  of  the  ciliar}-  body  exerts,  not  only  on 
the  injured  but  on  the  second  eye,  is  too  well  known.  Likewise,  where  a 
foreign  body  is  in  the  vitreous,  be  it  ever  so  small,  the  injury  to  the  lens 
becomes  a  matter  of  secondary-  consideration. 

Very  broad  incised  or  punctured  wounds,  as  well  as  total  destruction 
of  the  form  of  the  globe  are,  as  a  matter  of  course,  coraphcated  by  injuries 
to  the  lens. 

After  the  signs,  of  inflammation  have  disappeared,  one  must  take  into 
consideration  the  volume  of  the  traumatic  cataract  before  deciding  on  the 
,  method  to  be  employed.     If  the  diiference  of  volume  from  u  normal  lens 

is  but  slight,  one  will  be  called  upon  to  make  a  regular  operation.  The 
more  the  volume  is  reduced  the  hiore  nearly  will  the  cataract  come  under 
the  same  variety  as  the  secondary  cataracts. 

TEUP:  TEAUMATIC  CATAEACT.  if  the  traumatic  cataract  differs 
but  little  in  volume  from  the  normal  lens,  vision  may  be  totally  restored 
by  performing  a  technical  cataract  operation.  And  since  such  traumatic 
cataracts  usually  develop  as  soft  cataracts,  a  linear  extraction  is  indicated. 
JSTotM'ithstanding  the  fact  that  synechia  are  frequently  present  the  per- 
formance of  the  extraction  is  not,  as  a  rule,  connected  with  any  diificulty; 
the  results,  however,  are  not  very  encouraging,  depending  largely  on  the 
further  injury  to  other  parts  of  the  eye  at  the  time  of  the  accident,  and 
the  possible  infection  at  that  time. 

In  all  these  cases  one  should  not  forget,  before  operating,  to  test  the 
light  sense  and  the  projection. 

As  has  already  been  said,  the  operation  offers  no  special  difficulties. 
It  is  only  where  there  is  a  capsular  cataract  present,  or  where  the  capsule 
has  cicatrized  in  the  cornea,  iris,  or  ciliary  hody.  that  it  does  not  give 
easily  to  slight  traction;  hence,  one  should  not  attempt  to  draw  it  out  of 
the  eye  by  force,  though  it  does  interfere  with  sight.  Violent  trad  ion,  es- 
pecialJ;/  on  the  ciliary  hody,  will  he  folloirrrl  hij  the  most  detrimental  re- 
sults. Even  where  such  difficulties  aix'  nol  encountered,  frequently  the 
most  violent  reaction  follows.  The  ojK'rativc  ])r<)(H-dnre  leads  to  a  recur- 
rence of  the  cvclitis,  which  had  Inn  recently  subsided. 


368 

Naturally  the  irritability  of  the  eye  decreases,  the  longer  the  time 
elapsed  since  the  accident,  and  we  may  assume  that  a  period  is  reached  in 
every  eye,  at  which  time  no  evil  consequences  as  a  result  of  the  accident 
wall  exert  their  influence  on  the  proper  healing  of  the  operative  procedure. 
Hence,  it  would  be  advantageous  to  fix  a  time  when  it  would  be  well  to 
interfere.  It  has  been  said  that  a  traumatic  cataract  should  not  be  oper- 
ated earlier  than  the  sixth  or  eighth  week.  Such  a  rule  has  no  value,  since 
tinder  strict  asceptie  precautions  the  operation  can  not  of  itself  induce  any 
further  injury  to  the  eye.  But  where  the  case  is  complicated  by  iritis, 
cyclitis  or  choroiditis,  it  certainly  would  not  be  wise  to  undertake  an  oper- 
ation. During  this  time  Becker  laid  great  stress  on  the  circumcorneal 
injection,  and  laid  down  the  rule,  that  the  time  for  operating  had  arrived 
as  soon  as  the  pericorneal  injection  ceased  to  appear  in  grasping  the  con- 
junctiva with  the  forceps. 

Seldom  do  we  meet  with  a  membranous  cataract  {catarada  inem- 
hranacea),  or  a  secondary  cataract  {catarada  secundaria),  without  finding 
the  iris  bound  down  to  the  capsule  in  one  or  more  places.  Especially  in 
cases  of  traumatic  cataracts  do  we  find  broad  adhesions.  This  is  explained 
by  the  fact  that  during  the  period  of  swelling  or  immediately  following  the 
operation,  the  iris,  for  a  considerable  period  of  time,  remains  in  contact  with 
the  capsule.  P^requently.  however,  the  iris  receives  a  direct  injury,  or  at 
least  is  irritated.  Thus,  depending  on  the  character  of  the  injury  or  the 
processes  which  have  taken  place  subsequently,  will  we  find  a  simple  ad- 
hesion, a  broad  adhesion,  or  a  proliferation  of  cells  from  the  iris  into  the 
capsule.  A  deep  anterior  chamber,  the  irregular  form  of  the  pupillary 
edge  of  the  iris  which  is  adherent,  the  processes  of  an  opaque  membrane 
in  the  pupil,  pigmented  here  and  there,  possibly  vascularized,  are  all  land- 
marks for  the  diagnosis  of  the  above  condition.  If  a  piece  of  the  iris  has 
been  excised  at  the  time  of  the  o]jeration,  one  can  also  observe  how  the 
cloudy  membrane  gradually  is  lost  in  the  cicatrix  after  the  operation. 
In  such  a  case,  the  secondary  cataract  usually  lies  far  forward,  adherent  to 
the  iris,  or  the  cicatrical  tissue  in  the  cornea. 

In  the  simple  non-complicated  secondary  cataracts  a  disnsfoon  with 
one  or  two  needles  will  bring  about  llu'  desired  result,  and  with  a  higli  de- 
gree of  safety  and  efficiency.  This  operation  of  discission  aftei-  extraction 
is  not  without  its  dangers,  which,  according  to  Knapp,^  causes  glaucoma  in 
from  !-•<;  per  cent,  of  aphakic  eyes.  He  believes  that  tlie  charader  of  the 
secondary  cataract,  and   the   itniiinrr  »f  ofhn-kiinj   the  >aiue.  are   the   main 


1  Archives  of  ()plli:il..   \(.l.  XX  VII.   Xo.  o. 


I 


I 


369 

factors.     The  reac-lion — <i]aiu(mia  and  t yclitis— l)cin>i-  due  l<»  the  traction 
on  the  cicatricial  bands  stretching  to  the  ciliary  l)ody. 

If  the  secondary  cataract  is  fixed  in  the  wound  by  cicatrical  tissue, 
one  frequently  meets  with  success  by  making  an  iridectomie  in  the  oppo- 
site direction,  and  thus  regain  a  satisfactory  amount  of  vision;  since  in 
such  cases  the  greatest  portion  of  tlie  scconchuy  cataract  is  drawn  toward 
the  wound.  Frequently,  however,  tlic  hirgest  pupil  tills  uj)  again,  so  that 
even  a  second  iridectomie  is  without  result.  This  usually  is  tlie  case  where 
the  vitreous  is  detached  and  changed  to  connective  tissue,  and  takes  part 
in  the  formation  of  cicatrical  bands.  Such  a  result  can  not  be  foretold 
with  certainty  before  an  operation,  but  its  occurrence  is  to  be  feared  in 
all  cases  in  which  the  cicatrix  is  drawn  inward,  and  the  tension  is  reduced, 
when  the  iris  is  discolored,  and  the  membrane  in  the  ])upil  appears  to  be 
vascularized.  Both  of  the  last  symptoms  ai'e  indicative  of  abnormal  circu- 
latory conditions.  Jn  consequence,  dui'ing  the  operation,  the  anterior 
chamber  becomes  fdled  with  blood,  which  is  only  absorbed  after  many 
days  or  weeks.  When  one  finally^  does  get  a  good  view  of  the  conditions 
present,  one  finds  the  pupil,  which  had  again  been  made,  filled  up  with 
new  formed  tissue.  The  operative  procedure  has  awakened  anew  the  for- 
mation of  the  cyclitic  bands,  and  the  momentary  result  of  the  operation 
has  been  brought  to  naught. 

For  this  reason  other  operative  procedures  have  been  introduced  to 
take  the  place  of  the  iridectomie.  It  was  advised  that  the  cornea  be  severed 
by  a  3  mm.  wide  two-edged  knife;  then  go  in  with  a  pair  of  forceps  and 
cut  out  a  large  piece  of  the  iris,  so  as  to  lessen  the  chances  of  the  space 
filling  up  again.  (Agnew  A.  Weber.)  Later  on  DeWecker  favored  the 
iridectomy  (Annal.  d'Ocul.,  Tom.  LXX,  ]).  1-^3).  The  advantages  of  the 
iridectomie  which  he  makes  with  the  lance-knife,  and  his  '-Pince-Ciseaux." 
lie  in  the  fact  that  his  operative  procedure  does  far  less  injury,  because 
the  iris  is  not  drawn  out  to  be  excised;  but  since  it  is  held  tense,  he  simply 
incises  it  and  allows  it  to  retract.  Mooren  followed  this  suggestion.  Kruger 
advised  cutting  out  a  piece  of  tlie  membrane  witli  a  scissors-like  i)unch 
(Klin.  Monatsblatt,  1874,  p.  4'^9). 

Owing  to  the  influence  which  everything  wliicli  causes  tension  on  the 
ciliary  body  exerts  in  causing  cyclitis,  it  must  be  ai)parent  that  a  secondaiy 
operation  will  be  more  certain  of  bringing  about  a  good  result,  the  nu)re 
the  above  circumstances  are  avoided.  With  this  object  in  view  the  two 
following  operations  were  introduced: 

BOWMAN'S  METHOD.  Two  discission  needles  are  employed:  one 
is  passed  through  the  inner  ([uadrant  of  the  cornea  and  thi'ough  the  center 


370 

of  the  opacity:  the  second  needle  is  passed  throngli  tlie  onter  qnadrant  of 
the  cornea,  and  into  the  opaeit}'  close  to  the  first.  The  points  are  then 
separated,  and  tlins  a  hole  is  made  in  the  membrane. 

NO  YES'  METHOD.  A  puncture  and  counter  ])nnctur('  is  made  with 
a  Graefe  knife  in  the  horizontal  meridian  of  the  cornea,  and  as  the  knife 
is  withdrawn  it  is  made  to  puncture  the  secondarv  cataract.  Two  blunt 
hooks  are  now  entered  through  the  original  corneal  punctures,,  and  the 
points  passed  through  the  openings  in  the  membrane.  By  traction  the 
opening  is  enlarged  without  any  di'agging  on  the  iris  or  cilian'  body. 

THE  THERAPY  OF  LUXATION  OF  THE  LENS. 

The  treatment  of  luxation  of  the  lens,  just  as  that  of  cataract,  be  this 
of  traumatic,  spontaneous  or  consecutive  origin,  can  only  be  considered 
prophylaetically.  This,  however,  has  but  little  practical  value,  owing  to 
the  rarity  of  traumatic  luxation,  and  because  it  occurs,  even  less  frequently 
as  the  result  of  certain  occupations  than  the  traumatic  cataract,  which  is 
the  result  of  accidental  or  designed  injury  of  the  eye. 

The  attempt  was  made  a  few  times  (Hornig,  llGOa)  to  replace  in  the 
fossa  patellaris  a  loosened  or  even  a  partially  or  totally  dislocated  lens  by 
therapeutic  measures,  and  thus  to  bring  it  back  into  its  normal  position. 
Eduard  Meyer  (1160b)  reports  a  case  in  which  a  len.;;  which  was  dislocated 
upward  and  inward  returned  again  to  its  proper  position  in  the  pupil,  not- 
withstanding the  dislocation  on  the  other  eye  increased.  However,  it  did 
Dot  remain  fixed  in  its  position,  but  moved  about  when  the  eye  was  moved 
about  violently. 

Xo  cases  are  reported  in  wliich  it  has  been  ])ossible  to  stop  this  in- 
creasing ectopia.  Here,  just  as  in  cases  of  spontaneous  sinking  down  of 
the  lens,  one  can  not  ho])e  for  relief  until  we  have  discovered  the  cause. 
For  though  we  accept  Schirmer's  idea,  that  the  failure  of  the  lens  to 
grow  during  the  time  the  remaider  of  the  eye  is  :::rowing,  as  the  cause  of 
the  increasing  dislocation  in  cases  of  ectopia,  still  one  can  not  understand 
how  the  lens  is  to  be  urged  on,  or  the  remainder  of  the  eye  retarded  in  its 
growth.  Similar  reasons  are  given  for  the  cases  of  spontaneous  luxation 
following  fluidity  of  the  vitreous. 

If  the  dislocated  lens  is  still  ])artially  in  the  pu])inary  area  and  trans- 
parent, either  myopic  astygmatism  or  double  refraction  will  ensue.  The 
interference  with  sight  may  then  be  partially  or  totally  relieved  by  glasses. 
If,  however,  the  lens  is  cataractous.  the  interference  with  vision  may  be 
overcome  by  an  iridectomie.  ver}'  nuuii  in  the  same  niannei'  as  has  been 
advised  in  cases  of  zonular  cataract.  Kiiapp  was  the  first  (!)()."))  to  advise 
iridectomie  in  cases  of  luxated  cataractous  lenses,  which  still  occupied  the 
pupillary  area.    Naturally,  a  pei'manent  result  only  is  to  be  expected,  where 


371 

the  dislocated  cataract  lias  become  lixod.  Knapp's  case  was  a  dislocated 
traumatic  cataract  which  had  formed  adhesions  with  the  iris.  Since  in 
cases  of  shrunken  traumatic  cataract,  the  zonula  zinii  is  frequently  drawn 
to  one  side,  and  the  interspace  found  considerably  wider;  so  an  iridectomie 
properly  made  will  aid  us  in  restoring  a  very  considerable  degree  of  vision. 

Von  Graefe  was  the  first  to  practice  iridectomie  in  cases  of  zonular 
cataract  in  185.5. 

Though  we  might  look  upon  the  spontaneous  sinking  of  the  cataractous 
lens  out  of  the  pupillaiy  area  as  an  auto-cure,  it  may,  nevertheless,  if  it  is 
free  in  the  eye,  at  any  time  give  rise  to  secondarj'  glaucoma.  This  is  more 
apt  to  occur  when  a  freely  moveable  transpai'ent  or  cloudy  lens  gets  in 
the  anterior  chamber.     The  extraction  becomes  a  necessitv  in  both  cases. 


PART  V. 

THE  APHAKIC  P:YE. 

DEFINITION  AND  DIAGNOSIS  OF  APHAKIA.  According  to 
the  suggestion  of  Donders  (Ametropie  en  hare  gevolgen,  Suermann  en 
Donders,  1860,  p.  8T),  we  designate  that  condition  in  which  the  lens  is 
absent  from  tlie  dioptric  system  of  the  eye  by  the  term  Aphal-'ia  (a  ])ri- 
vativum  and  tpax^  the  lens  or  bean). 

Aphakia  may  be  produced  by  different  causes.  It  occurs  most  fre- 
quently as  a  result  of  operation  for  cataract  or  of  an  injury.  In  both 
ways  the  lens  may  either  be  removed  from  the  eye  at  once,  or  after  opening 
of  the  capsule  be  resorbed  in  the  eye,  or  simply  be  depressed  in  the  vitreous. 
Under  the  latter  condition  the  lens  is  still  in  the  eye,  and  may  even  remain 
transparent  for  a  long  time.  We  are,  however,  justified  in  designating  this 
condition  as  aphakia,  since  the  lens  can  no  longer  iniluence  the  direction 
of  the  rays  of  light.  Tn  cases  of  incomplete  luxation  (be  this  traumatic  in 
its  nature  or  spontaneous,  or  as  in  cases  of  ectopia  lentis,  in  which  not  in- 
frequently part  of  the  pupil  is  free,  whereas  in  the  other  portion  of  the 
pupil  the  rays  of  light  as  they  enter  are  acted  on  by  the  lens),  there  exists 
a  double  condition  of  refraction.  As  a  rule,  myopia  and  hypermetropia 
are  present  at  the  same  time,  and  we  have  before  us  a  case  of  monocular 
diplopia.  The  myopia  is  due  to  the  increased  curvature  of  the  surface  of 
the  luxated  lens,  and  hence  in  an  emmetropic  eye  tliis  does  not  become 
very  great.  Whereas,  the  hyperopia  differs  in  no  way  from  the  refractive 
condition  of  a  completely  aphakic  eye. 

It  is  not  always  an  easy  matter  to  determine  the  presence  of  aphakia 
at  first  sight.  The  appearance  of  the  eye  depends  largely  on  the  method 
of  operation  employed,  the  kind  of  injury  produced,  and  the  manner  in 
which  the  process  of  healing  progressed.  In  the  foregoing  chapters  all 
those  symptoms  have  been  enumerated  which  could  serve  to  aid  us  in 
making  the  diagnosis  in  every  ])ossil)le  case. 

Whether  the  operation  or  tlie  injury  has  been  followed  l)y  an  occlusion 
of  the  pupil,  one  can  judge  by  the  external  ap])earance  of  the  eye.  Where 
the  operation  was  combined  with  an  iridectomie,  or  the  lens  has  escaped 
from  the  eye,  in  consequence  of  a  rn])turi'  of  the  sclera,  the  coloboma  of 
the  iris,  or  the  displaced  pu))il,  will  lead  us  to  investigate  the  coiulition,  and 
lead  us  to  dctcrniinc   wliclhcr  or  not  the  lens  is  urescnt.      I>\it   if  wc  are 


,-..ssfi 


in. 


373 
1  was  made  without  an 
at  ion  or  a  spontaneou.s 


SCISSI 

r  the  eye.  the  aphakia  will  be  character- 
he  presence  oi'  iridodonesis,  the  absence 
and  hy  the  liii^h  decree  of  hyperopia. 
aiilei'ior  ehaiidiei'  will  he  all  the  more 
iilly  Ihe  shallower  the  an- 
eases    of    luxation    (d'    the 


i>e(|i 


[•a  ted     ey 
)tl 


..f    Ih 


which 


dealing  with  a  ease  in  which  a 
iridectoniie.  or  a  case  of  siiupl( 
sinking  of  the  lens  in  the  depth 
ized  by  a  deep  antei'ioi'  chaiid)e 
of  the  I'urkinj.'  Iigure>  of  the  le 
^rhis  ahnoriual  depth  of  t 
apparent  the  oldei'  the  individii 
terior  chandler  on  the  non-op 
lens,  or  e(  topia.  it  is  the  une(|ual  d( 
directs  our  attention  to  the  i)ro])ei'  diagnosis. 

Iridodonesis  aloiU'  is  not  positive  evidence  of  the  absence  of  the  lens, 
since  jieripheric  t reniulonsness  of  the  iris  has  lieen  observe<l  in  cases  of 
high  myopia:  also  in  cases  of  fluidity  (f  the  vitreous,  without  the  lens 
being  luxated.  Trembling  of  the  iris  is  not  seldom  wanting  in  cases  in 
which  the  lens  is  absent,  as  per  examiile.  in  cases  in  which  the  iris  is  bound 
to  the  capsule  hy  syneclda,  hut  also  where  it  is  entirely  fi'ee.  It  is  possible 
that  this  is  duv  to  the  develo])ment  of  an  enornums  crystalline  pearl.  This 
trembling  of  the  iris  becomes  more  noticeable,  in  cases  in  which  either 
the  lens  moves  about  freely,  or  in  which  the  vitreous  which  contains  the 
lens  has  become  fluid. 

Parenthetically  it  may  lie  here  stated,  that  often  in  old  people,  wliore  tht- 
iris  has  not  been  excised,  tlie  reaction  of  the  pupil  is  not  only  as  it  should  be. 
oonsideriufi  tlie  ajie.  l»n  freciuently  is  more  active,  and  even  in  cases  in  which 
a  coloboma  lias  been  made,  tlie  iris  reacts  to  lijiht. 

The  ]u-esence  of  the  reflected  pictures  on  the  surface  of  the  lens  in 
doubtful  cases,  decide  the  presence  of  the  lens  in  the  pupillary  area.  Fre- 
quently on  focal  illumination,  especially  when  an  additional  lens  is  used 
to  enlarge  the  images,  can  the  arrangement  of  the  lens  fibres  be  detected, 
or  at  least  can  we  recognize  its  presence  by  the  grey  reflex  of  its  substance. 
If  this  experiment  gives  us  a  negative  result,  we  can  only  be  positive  of 
the  absence  of  the  lens,  when  aside  from  the  reflected  picture  on  the 
cornea,  there  still  remains  a  second  in  the  ]»u])il.  For  since  in  most  cases, 
even  when  the  operation  has  been  perfectly  successful,  the  posterior  cap- 
sule remains  in  the  pTipil.  this  can  always  give  rise  to  a  reflected 
image.  'J'his,  however,  as  a  rule,  owing  to  the  folds  in  the  capsule,  its 
want  of  curvature  is  exceedingly  large,  indistinct  and  distorted;  never- 
theless, I  have  rejieatedly  been  able  to  observe  a  retU'x  moving  in  the 
same  direction  as  the  source  of  light.  Woinow  ^  has  convinced  himself, 
that  this  is  an  upright  image,  and  he  concludes  that  this  reflecting  surface 


lA.  f.  O.,  XIX.  3,  p.  110. 


374 

must  have  been  slightly  convex  anteriorly.     He  even  went  a  step  fai'ther 

and  noted  that  these  i^ictures  grow  smaller  in  looking  at  near  objects. 

However,  the  images  were  too  indistinct  to  be  measured  with  the  opthal- 

mometer. 

Even  after  an  extraction  in  which  the  capsule  is  also  removed,  one 
can  frequently  demonstrate  a  reflecting  surface,  posterior  to  the  plane  of 
the  pupil.  In  the  case  of  a  woman,  36  years  of  age,  from  both  of  whose 
eyes  Becker  removed  shrunken  congenital  cataracts,  and  in  M-hich  the 
microscope  had  given  the  absolute  certain  diagnosis  that  the  entire  capsule 
had  been  removed,  this  reflecting  surface  could  not  only  be  plainly  recog- 
nized, but  on  dilating  the  pupil  and  using  the  opthalmoscope,  one  could  see, 
most  distinctly,  the  radially  placed  torn  fibres  of  the  zonula  zinii. 

The  degree  of  hypermetropia  is  of  itself,  in  cases  of  emmetropic  and 
hypermetropic  eyes,  sufficient  to  make  a  diagnosis  of  aphakia,  for  it  is  a 
very  exceptional  thing  to  find  a  hyperope  of  h  or  ^,  in  a  case  where 
the  lens  is  still  present.*  Degrees  of  i  to  |  are  very  seldom  due  to  a 
short  axis.  The  diagnosis  of  aphakia  in  cases  of  high  myopia,  however, 
can  not  be  determined  optometrically. 

THE  0?>TICAL  SYSTEM  IN  APHAKIx\.  "Owing  to  the  removal 
of  the  lens,  the  complicated  dioptric  system  which  exists  under  normal 
conditions  in  the  eye,  now  becomes  the  simplest  of  which  it  is  possible  for 
us  to  conceive.  Notwithstanding  its  difl'erent  histological  structure,  we  may 
look  upon  the  cornea  as  having  an  index  of  refracting  about  the  same  as 
that  of  the  aqueous  humor.  The  very  slight  difference  which  was  found 
in  the  coefficient  of  refraction,  was  determined  by  measurements  made 
on  the  dead  cornea.  If  we  examine  a  living  cornea  in  the  aqueous,  as  is 
well  known,  differences  will  only  begin  to  manifest  themselves  after  a 
time,  and  these  are  to  be  looked  upon  as  due  to  a  gradual  death  of  the  ti^ue. 
Hence,  during  life  the  cornea  is  not  only  to  be  looked  upon  as  homogenous, 
but  as  optically  like  the  aqueous." 

"Likewise,  there  is  scarcely  any  optical  difference  between  humour 
aqueous  and  corpus  rifreum.  Already  the  younger  De  la  Hire  found 
(1707),  at  the  time  he  was  called  upon  by  the  Akademie  to  answer  the  new 
teachings  of  Brisseau,  contrary  to  what  he  had  believed,  that  a  mixture  of 
aqueous  and  vitreous,  taken  from  a  pig's  eye,  remained  perfectly  clear,  and 
thus  proved  that  these  two  fluids  neither  exerted  any  chemical  change  on 
each  other,  nor  did  they  have  a  different  coefficient  of  refraction.  All  later 
investigations  have  simply  further  proven,  that  both  not  only  possess  the 
same  index  of  refraction,  but  that  this  is  the  same  as  that  of  distilled  water." 

a  In  order  to  translate  the  inch  scale  to  the  Dioptr»\  innltijily  the  traction  by 
forty.     Thus,  \  X  40=  Y==  10  T). 


i 


375 
"If  we  will  simply  consider  the  results  of  the  luvestifiations  of  the 
four  last  investigators,  TIelmholtz,  C'yon,  Fleischer,  and  Ilirschberg,  we 
will  see  that  they  respectively  place  the  coefficient  of  refraction  at  1.3;5G5_, 
1.33532,  1.33T3,  1.337  1,  and  that  of  the  vitreous  at  1.3383,  1.33566,  1.3369, 
1.3360,  and  we  will  further  see  that  all  thos<^  figures  only  differ  in  the  third 
decimal  place.  And  further,  if  we  will  take  into  consideration  that  Cyon 
made  his  calculations  on  the  ox's  eye,  and  that  though  Helmholtz  and 
Hirschberg  have  found  difl'erences  between  aqueous  and  vitreous,  which  ex- 
ceed somewhat  0.001,  which ho\vover,may  be  ignored, we  certainly  can  not  go 
amiss  if  we  accept  as  a  l)asis  for  our  work  the  figure  attained  by  Fleischer. 
But  since  Fleischer  has  drawn  attention  to  the  fact,  that  owing  to  the 
increased  temperature  of  the  blood  in  the  living  eye,  we  will  have  to  reduce 
the  refracting  indices  of  aqueous  and  vitreous  about  C.  0.001;  hence,  since 
our  calculations  are  to  be  made  for  the  living  eye,  we  may  place  the  index 
of  refraction  of  the  fluid  media  of  the  eye  in  aphakia— 1.3360,  which  agrees 
almost  exactly  with  the  index  of  refraction  of  distilled  water  as  determined 
by  Brewster— 1.3358." 

''According  to  Listing  it  is  not  the  surface  of  the  cornea  but  rather  a 
capillary  surface  of  tears  which  is  to  be  looked  upon  as  the  refracting  sur- 
face. Hence,  Hirschberg  had  a  happy  thought  when  he  determined  to 
estimate  the  index  of  refraction  of  the  tears.  This  equals  1.33705,  and 
hence  only  differs  in  the  third  decimal  place.  Hence  the  cornea,  the  center 
of  which  only  comes  under  consideration  here,  is  to  be  looked  upon  as  a 
perfectly  parallel  surface,  placed  between  two  fluids  of  equal  indices  of 
refraction,  and  hence  it  can  not  exert  any  dioptric  influence." 

The  same  may  be  said  of  the  capsule  when  this  has  been  retained  In  the 
eye  after  a  cataract  operation.  It  may  be  folded,  and  reflect  the  light  and 
coniain  cloudy  masses  here  and  there,  absorb  the  light  and  cause  dispersion, 
but  it  can  never  act  as  a  refracting  medium.  ^ 

"This  capillary  sheath  of  tears,  which  fills  out  all  the  uneven  places 
on  the  corneal  surface,  and  which  is  to  bo  looked  upon  as  the  true  refract- 
ing surface,  is  dependent  for  its  form,  as  a  matter  of  course,  on  its  under- 
lying structure,  the  cornea.  Its  curvature  is  determined  by  its  catoptric 
effect;  that  is,  by  the  size  of  its  images,  and  its  power  of  refraction  depends 
on  this  curvature  and  the  coefficient  of  refraction  (1.336)  of  the  transpar- 
ent media.  Though  the  cornea  is  not  spherical,  but  has  rather  an  ellip- 
soidal cuiwafure,  one  may  ignore  this  departure  from  tlie  globular  form; 
since  in  the  first  place,  at  that  point  in  the  center  of  the  cornea  where  the 
visual  Hne  cuts  the  same,  this  departure  in  a  single  meridian  is  exceeilingly 
slight;  and  secondly,  because  in  making  the  optometric  examination  of 
the  refractive  condition  of  the  aphakic  eye,  in  order  to  prescribe  cataract 
glasses,  we  only  make  use  of  spherical  glasses,  and  the  choice  of  the  same 
is  nearly  always  confined  to  the  condition  of  the  refraction  of  ihe  horizontal 


376 

meridian.    Hence,  for  the  ])resent  we  will  not  consider  a  congenital  or  ac- 
quired asymetrie  in  the  curvature  of  the  cornea.    (Ast5'gmatism.)" 

"The  simple  dioptric  system  of  the  aphakic  eye,  which  we  shall  take 
as  our  model  for  all  our  future  considerations,  consists  of  a  spherically- 
curved  refracting  surface  and  two  refracting  media,  the  atmosphere  which 
has  an  index  of  refraction  1.000.  and  the  thiid  media  of  the  eye.  which 
have  a  refractive  index  1.33()." 

"If  we  now  also  know  the  radius  of  curvature  of  the  refracting  sur- 
face, we  can  easily  determine  the  cardinal  points  of  the  system,  according 
to  Helmholtz's  simplified  formula  of  Gauss,  and  we  can  easily  determine 
the  interesting  equations  as  to  the  length  of  the  axis  of  an  aphakic  eye  of 
known  refractive  condition,  and  vice  veisa,  given  the  length  of  the  axis; 
also  concerning  the  size  of  the  images  at  a  given  distance,  and  vice  versa; 
also  concerning  the  enlargement  on  combining  the  cataract  glasses  \Wth 
the  aphakic  eye." 

Owing  to  the  great  simplicity  of  sucli  a  formula,  as  compared  witli  that  of 
the  complicated  system  of  a  complete  eye.  Listing  came  upon  the  idea  of  sub- 
stituting the  dioptric  strength  of  his  average  schematic  eye  by  a  refracting  sur- 
face: however,  retaining  the  position  of  the  posterior  nodal  poiut.  and  thus  he 
constructed  his  so-called  reduced  eye. 

"However,  notwithstanding  the  analogy  which  exists  between  the 
reduced  and  the  aphakic  eye,  they  differ  in  that  in  the  latte^  case  we  are 
always  in  a  position  to  measure  the  curvature  of  the  cornea  with  the  opthal- 
mometer,  so  that  we  are  no  longer  dealing  in  the  abstract,  but  are  met  by 
a  condition  of  affairs  which  really  exists." 

"Hence,  in  arriving  at  the  following  general  formulas  we  need  not 
confine  ourselves  to  the  computations  of  Listing  and  Helmholtz  in  their 
schematic  eyes.  This  is  the  result  of  the  work  of  Bonders  (1.  c,  p.  208. 
Eup.  Translation,  1864,  p.  310),  in  that  he  does  not  use  the  average  radius 
of  curvature  of  the  ccrnea  of  the  aphakic  eye.  as  computed  by  Listing  and 
Helmholtz,  8  mm.,  but  he  uses  the  results  of  his  own  measurements,  made 
on  eyes  of  old  men,  the  average  of  which  he  placed  at  7.7  mm." 

"Under  these  conditions  the  average  measurement*  of  the  ajdinkic  eye 
will  be  as  follows:  Corneal  radius,  7.7  iniu.:  index  of  refraction  of  the 
media  of  the  eye.  1.33()0.  The  antorioi-  focal  distance,^^  =  '^"^.!>l  ]nin. 
The  posterior  focal  distance,  <p'^  =  '30.(3l  mm." 

"From  this  we  see  thai  tlu'  visual  axis  in  a  case  of  normal  curvature 
of  the  cornea  must  have  a  length  equal  to  30.61  mm.,  in  oi'der  that  parallel 
rays  of  light  may  come  to  a  focus  on  the  retina  in  a  case  where  the  lens 
is  wanting.  But  since  the  length  of  the  axis  is  almost  always  much  shorter. 
hence  in  general  we  find  the  aphakic  eye  hyperopic  to  a  liigh  degree. 
From    now    on    1    shall    designate    the    hyperopia    as    0 phukir    In/pcropia." 


377 
"In  order  to  Hud  the  degree  of  aplmkic  hypeniu'troidn,  with  a  given  length 
of  the  visual  axis,  we  need  only  ealeulate  to  what  point  behind  the  cornea  the 
incidental  rays  must  converge,  in  order  after  refraction  by  the  cornea,  to  unite 
on  the  retina.  This  is  done  according  to  Hehnholtz's  formula  (1.  c.  p.  44 1. 
fr=Y^'lr  *"<!  ///=  f_l.  ,  in  which  /^  the  length  of  the  visual  axis  and  /^  the 
point  sought  behind  the  cornea. 

According  to  the  same  formula  Ave  can  also  d(>teimine  the  length  of  the 
visual  axis,  when  tlie  focal  distance  of  the  glass  which  corrects  the  hyperme- 
tropia  and  its  distance  from  the  center  of  the  cornea  are  known.  Accordingly, 
as  this  glass  is  held  at  a  greater  or  less  distance  from  the  eye.  eyes  with  vary- 
ing lengths  of  the  visual  axis  can  see  in  the  distance." 

EMMETROPIC  APHAKIA.  "The  finding  of  tlie  proper  glass  with 
which  an  aphakic  eye  can  see  in  the  distance  is  practically  a  matter  of 
experiment.  In  order  to  do  thi.s,  we  either  follow  the  suggestion  of  Bond- 
ers, using  a  luminous  point;  or  we  use  the  Snellen's  test  types,  such  as  are 
usually  employed  in  testing  cases  of  refraction.  By  this  means  we  at  the 
same  time  gain  an  idea  as  to  the  acuity  of  vision." 

E.\])erience  has  taught  us  tliat  a  glass  which  has  a  focal  length  of 
more  than  3.5"  (+11  D),  will  be  required  in  order  to  see  distinctly  in  the 
distance.  In  the  last  hundred  ca.'ses  operated,  thirty  -  five  received 
glasses  of  ^,  (+  11  D);  fifty-two  glasses  ranging  between  ^  (+10  D)  and 
^  (+  11  D).  Aside  from  this'  twenty-four  glasses  No.  ^  (  +  10  D);  so 
that  by  adding  these  together,  we  find  that  seventy-six,  about  three-quarters 
of  all  those,  received  cataract  glasses  of  ^  to  -^.  Only  eight  patients 
saw  distinctly  in  the  distance  with  stronger  glasses,  and  sixteen  with  weaker 
glasses.  The  weakest  glass  which  I  ordered  was  for  y^,  the  strongest  ^ 
This  agrees  with  Snellen's  statements,  who  gave  a  glass  of  ~  in  65  per 
cent,  of  cases;  in  11  per  cent,  stronger,  and  in  24  per  cent,  weaker  glasses. 
(If  Westhofi"  doubts  these  figures  for  acquired  H,  this  must  evidently  be 
a  clerical  error  for  Bonders,  from  whose  reports  the  above  statements  are 
taken,  is  likewise  of  the  opinion  that  in  the  majority  of  cases  a  glass  of 
^  to  ^  (+10D  to+ 11  I))  will  he  necessary  to  see  distinctly  in  tlie  dis- 
tance.)    The  conditions  are  confirmed  by  all  rejjorts. 

"If  we  assume  the  average  distance  at  which  a  cataract  glass  is  placed 
from  the  cornea,  equal  to  0.5",  we  would  still  find,  taking  into  con.sider- 
ation  the  distance  of  the  nodal  point  from  the  cornea,  in  the  majority  of 
cases  after  the  cataract  operation,  the  ac(|uired  H  would  equal  Ji  ,\r-  the 
radius  of  cornea  being  7.7  mm;  the  length  of  the  ojitical  axis  being  23.86 
(7)  mm." 


378 

"(In  the  case  of  the  schematic  eye,  the  radius  of  the  cornea  would  be 
8  mm.,  and  the  length  of  the  optic  axis  would  be  24.5  mm.,  which  would 
be  more  than  above.)  Hence  such  an  eye,  haA'ing  a  corneal  radius  of  7.7 
mm.,  an  index  of  refraction  of  1.3360,  and  an  optical  axis  of  23.86  (7)  mm., 
may  be  looked  upon  as  an  enmieti-opic  eye.  We  therefore  call  it  the  emme- 
tropic-aphal-ic  eye.'" 

"Very  frequently,  however,  the  distance  of  the  center  of  the  glass  is  farther 
removed  from  the  center  of  the  cornea  than  0.5".  Where  the  distance  of 
the  glass  is  0.75",  the  length  of  the  optic  axis  is  reduced  (7.7  mm.  radius) 
to  23.39  mm.  Hence,  it  is  still  considerably  greater  than  is  the  case  in  Helm- 
holtz's  schematic  eye  (22.23).  If  we  will  now  assume  that  most  cases  of  senile 
cataract  occur  in  eyes  Avhich  were  emmetropic  before  they  became  cataractous, 
and  became  affected  with  senile  hypermetropia,  we  come  upon  a  contradiction 
between  tlie  average  length  of  the  optical  axis  as  determined  by  Helmholtz, 
and  ourselves,  after  cataract  operations,  aud  a-ecording  to  optometric  exami- 
nations." 

In  any  special  case,  we  need  not  satisfy  ourselves  with  the  average 
length  of  the  radius  of  the  cornea  after  a  cataract  operation,  for  we  can 
obtain  this  accurately  by  measurements  made  with  the  opthalmometer. 
Here  assuming  that  the  index  of  refraction  of  the  vitreous  has  not  changed, 
we  can  obtain  the  exact  length  of  the  axis.  In  the  following  table  I  have 
taken  those  in  which  the  corneal  radius  was  measured  in  the  horizontal 
meridian  with  the  opthalmometer  before  the  operation  by  Eeuss  and 
Woinow.  Since  the  distance  from  the  eye  is  not  stated,  I  have  taken  this 
to  be  in  one  case  0.5";  in  another  as  0.75".  From  these  tables  it  also  be- 
comes evident,  that  the  average  length  of  the  axis,  without  exception,  is 
greater  than  is  the  schematic  eye." 

Hence,  it  follows,  that  not  only  the  corneal  radius  given  is  too  great, 
but  that  also  the  refractive  strength  of  the  lens,  be  this  the  result  of  im- 
proper position  or  a  too  great  absolute  strength,  has  been  assumed  too  great. 


379 


T 

ABLE 

VII. 

XAME- 

,/.. 

Focal  Distance 

of  the  Glasses 

Ordered  for 

Distance. 

y;-=- 

H  aph. 

Length 
of  the 
Visual 
Axi.s 

///     - 

//  aph. 

Length 
of  Axis 

Pischinger      .    . 
Nitsch     .... 
Werhotta    .    .    . 
Pohlhammer     . 
Donabaum     .    . 
Furtlehmer   .    . 

8  0780 
7.9275 
7.7282 
7.4964 
8.1794 
7.8976 
7.6108 

9.^^5 
6.00 
4.5 
3.75 
3.5 

3.25 
3.00 

9.^^00 
5.5 
4.0 
3.25 
3.00 

2.75 
2.5 

1 

8.H6 

1 
0.15 

1 
3.65 

1 
2.90 

1 
•2.65 

" 

2.40 

1 
2.1.-) 

29'^  33 
27.10 
25.20 
24.84 
24.86 
24.20 
23.71 
23.05 
23.68 
23.07 
21.93 

8.  ^'7 
5.25 
3.76 
3-00 
2.75 

2.5 
2.25 

H.-IO 

1 
4.iliJ 

1 
3.40 

2.6.=p 

1 
2.40 

2.15 

1 
1.90 

26.' '80 
26.66 
25.70 
24.36 
24.34 
23.70 
23.04 

7.4155 

22.60 

Dolak      .        .    . 

7.8740 

23.17 

3Iatcheky  .    .    . 

7.5862 
7.3644 

22.54 
21.34 

i*h=  Radius  of  horizontal  meridian  of  cornea  ;  /,  as  in  formula  on  page  376.     H. 
aph,  aphakic  hypermetropia ;  /,  as  given  on  page  376,/  determined  length  of  axis. 

MYOPIC  AND  HYPEEMETEOPIC  APHAKIA.  'If  the  eve  was 
mj-opic  previous  to  the  operation,  it  will  require  weaker  glasses  after  the 
operation.  And  likewise,  where  an  eye  requires  a  weaker  glass  after  oper- 
ation to  see  in  the  distance,  we  conclude  that  the  eye  must  have  heen  myopic. 
We  can  then  also  approximately  judge  the  degree  of  myo]iia.  Donders  repoi-ts 
a  case  in  which  an  aphakic  eye  was  not  improved,  either  by  use  of  a  plus 
or  minus  glass.  In  this  case  the  casual  axis  of  an  eye  which  had  become 
emmetropic  by  aphakia,  must  have  had  a  length  of  30  mm.,  and  from  this 
we  may  draw  the  deduction  that  as  long  as  the  lens  was  present  in  the  eye 
there  must  have  existed  a  myopia  of  al)out  ^  ( — 10  to  — 11  D).  A  glass 
of  \  (+  o  D)  or  less  is  now  .sufficient  to  see  in  the  distance,  and  not  in- 
frequently patients  state  that  they  now  see  better  witli  a  +4  D,  or  +  5  D,or 
less,  than  they  formerly  did  with  the  inyojiia  of  i  ( — 8  D)  or  more." 

"Donders,  who  drew  attention  to  the  fact  that  zonular  cataract,  as  a 
rule,  is  associated  with  myopia,  was  given  the  opi)ortunity  to  measure  the 
radius  of  curvature  of  the  cornea  in  three  cases,  which  were  myopic  before 


38o 

and  hypertropic  after  the  operation,  and  from  this  lie  determined  the  length 
of  the  optic  axis.  Table  VIII  shows  their  length.  It  happens  that  in 
the  first  case  the  axis  of  curvature  of  the  cornea  is  somewhat  shorter,  and 
in  the  two  latter  somewhat  longer  than  usual.  Hence,  from  the  length  of 
the  visual  axis  one  can  determine  the  degree  of  myopia." 

TABLE  VIII. 


AMETROPIA. 

Curvature 

Radius  of 

Cornea. 

Calculated 
Length  ok 

Before  the  Operation. 

After  the  Operation. 

THE  Visual 
Axis. 

M=l:6 

M=l:8.5 

M=l:24 

H=l:5.12 

H=l:4.5 

H=l:3.2 

7.6 

7.92 

8.04 

25.96 
26.39 
25.02 

''We  find  that  congenital  hyperopia  acts  in  exactly  the  opposite  man- 
ner. However,  Bonders  declares  that  one  seldom  finds  an  aphakic  H  > 
1:2.5.  1  do  not  remember  that  I  even  prescribed  a  stronger  convex  glass 
than  |.  In  the  two  hundred  cases  reported  by  Snellen,  I  find  only  two 
cases  in  which  2^  was  prescribed.  One  of  these  cases  had  been  previously 
operated  on  (iridectomie)  for  glaucoma,  and  with  success." 

AVERAGE  MEASUREMENTS  OF  THE  EMMETROPIC  EYE. 
"Based  on  the  values  given  for  the  emmetropic  eye  in  the  foregoing  para- 
graph, we  can  construct  an  absolutely  emmetropic  average  eye,  if  we  will 
reconstruct  the  lens  within  the  same.  Of  this  lens  we  neither  know  its 
focal  distance  nor  the  position  of  its  principal  points;  however,  we  do 
know,  that  it  must  fulfill  certain  conditions,  namely,  to  cause  rays  of  light 
which  enter  the  aqueous  converging,  so  as  to  meet  at  30,  (>!  mm.  behind  the 
cornea,  to  so  alter  their  course  as  to  come  to  a  point  at  28.36  mm.  To  this 
problem  there  are  an  indefinite  number  of  solutions,  in  that  the  focal  dis- 
tance of  the  lens  is  dependent  on  the  position  of  the  principal  points,  and 
vice  versa.  The  calculation  has  shown,  that  a  lens  having  the  focal  dis- 
tance, as  in  the  schematic  eye  (43.707  mm.),  answers  the  above  condition 
when  its  conjoined  principal  point  is  9.754  mm.  posterior  to  the  cornea. 
According  to  our  anatomical  knowledge  such  a  position  of  the  lens  is  an 
impossibility.  However,  if  wc  will  calculate  tlie  focal  distance  of  a  crystal- 
line lens,  the  o])tical  center  of  wliich  shall  be  in  tlie  uodal  point  of  the 
aphakic  eye  (7.7  mm.  behind  the  center  of  the  coi'nea).  and  which  shall 
answer  the  ahovc  conditions,  we  will  obtain  a  value  of  54. S4  nun.  Such  a 
position  of  the  lens  is  a  po.ssibility,  though  it  has  not  heen  anatomically 
proven.  Since  following  an  operation  we  desire  to  calculate  for  the  aphakic 
eye  what  the  previous  i-cfi'activc  condition  was.  wc  must  dctci-uiiuc.  asjias 


38i 
already  been  explained,  what  tlie  true  conditions  are  in  the  emmetropic 
eye,  and  to  do  this  the  schematic  eye  does  not  suffice;  hence,  1  jjive  below 
the  calculation  made  for  an  average  emmetropic  eye." 

r=7.7  mm.,  ^^^  1.3360,  /"j  =23.86  mm.,  focal  distance  of  the  lens=54  84 
mm.  and  position  of  the  8ame=7.7  mm.,  i^i=16.15  mm.,  i''2=:21  59  mm. 
Position  of //i=2.25  mm.,  H^=2.28  mm.,  A"i=:7. 68  mm.,  7^2=7.71  and 
finally  the  position  of  i'\=— (16.16 — 2.25)=: — 13.90  mm.,  and  the  position 
of  ^2  =23. 87  mm. 

P'inally,  it  is  interesting  to  note  that  according  to  Helmlwltz  the  focal 
distance  in  ihe  air  of  the  lens  in  his  schematic  eye  is  8.9  mm.;  whereas,  ac- 
cording to  ours  this  has  fallen  to  11. 1(5  mm." 

"In  the  constructicn  of  our  average  emmetropic  eye  we  have  made  two 
assumptions.  It  is  only  an  assumption,  and  has  not  been  proven  that  an 
aphakic  eye,  which  has  its  H.  neutralized  by  a  lens  of  3.5"  focal  distance, 
placed  at  0.5"  distance  from  the  centre  of  the  cornea,  must  have  been 
emmetropic  before  the  operation.  Owing  to  the  very  great  importance  of 
the  propositions  which  must  follow,  it  is  a  matter  of  the  greatest  im- 
])()rtance,  and  its  value  can  hardly  be  estimated,  if  it  were  to  become  pos- 
sil)le  to  determine  the  aphakic  H.  exactly,  in  eyes  in  which  the  condition 
of  refraction  is  known.  The  second  assumed  factor  is  the  position  of  the 
the  lens.  If  it  should  ever  happen  that  we  should  be  enabled  to  make  an 
extraction  on  an  eye  wdiich,  before  becoming  diseased,  had  been  under  ob- 
servation, and  in  which  we  had  estimated  the  refraction,  the  corneal  curva- 
ture, the  depth  of  the  anterior  chamber,  and  the  curvature  of  the  anterior 
surface  of  the  lens;  and  again,  after  the  extraction,  estimate  its  refraction 
and  its  corneal  curvature,  this  would  certainly  materially  aid  us  in  our 
estimates,  concerning  our  knowledge  of  the  lens  system  in  the  living  human 
eye.  As  this  w^ould  also  aid  us  in  determining  the  index  of  refraction  of 
the  lens  and  its  individual  lamella,  the  only  fact  still  remaining  unknown 
would  be  the  form  of  the  posterior  surface  of  the  lens,  and  on  which  the 
thickness  of  the  lens  depends.  Under  these  existing  conditions  it  seems 
proper  that  the  following  figures  should  be  stated  as  having  a  direct  bear- 
ing on  the  question. 

TABLE  IX. 


Name. 

Age. 

Non-Operated. 

Oper.\ted. 

EVE. 

R. 

,.. 

Eve 

Operation. 

//  a//i. 

pA. 

I^ENGTH 

OF  Axis. 

Schweller  .  . 

Weiss 

Hilbert 

Kircher    .  .  . 

11 
11 
40 
83 

L. 
L. 
R. 

36~ 

""36- 
!_ 

+  -4 

7.74 
7.37 
7.fi414 

7.2828 

R. 
R. 
L. 
R. 

Discission 

(  Discissio  mo- 
1        dificalo 

Graefe's  Ext. 

, 

7.526 

23.086 

2.4 

1 

3.17 

1 
4.22 

7.247 

24.456 

''The  above  table  contains  a  series  of  figures  bearing  on  the  condition 


382 

found  existing  in  four  individuals,  in  each  of  whom  an  eye  had  been  oper- 
ated on  for  cataract;  whereas  the  other  eye  still  had  a  transparent  lens,  and 
in  which  the  refractive  condition  could  be  estimated  by  the  test  types  and 
the  opthalmoscope.  An  exact  inquiry  into  the  liistory  of  the  case  showed 
that  previous  to  the  disease  the  patient  had  seen  equally  good  with  both 
eyes.  In  order  to  determine  the  length  of  the  axis  of  the  aphakic  eye,  the 
distance  between  the  glass  and  the  cornea,  was  estimated  as  nearly  as  pos- 
sible. Though  the  radius  of  the  cornea  may  be  diminished  in  its  horizontal 
meridian  as  a  result  of  the  operation,  this  will  not  shorten  the  length  of 
the  axis  of  the  eye.  Hence,  one  may  safely  transfer  the  investigation  of 
this  point  to  the  sound  eye.  In  the  fourth  case  the  length  of  the  axis  ap- 
pears relatively  short,  owing  to  the  abnormally  increased  corneal  curva- 
ture; especially  if  one  will  compare  this  case  with  an  analogous  one,  case  2, 
in  table  VIII.  In  that  case  the  corneal  radius  was  abnormally  large,  here 
it  is  abnormally  small.  The  minimum  measurement,  according  to  Bon- 
ders, of  7.28  mm.,  coincides  exactly  with  the  radius  of  Kircher's  case.  A 
portion  of  the  myopia  hence  is  dependent  on  the  cornea,  and  in  this  case 
we  are  dealing  with  one  of  corneal  myopia.'" 

"Conditions  which  exist  between  aphakic  H.,  length  of  the  optic 
axis,  and  also  the  E.  previous  to  the  operation.  In  preparing  the  following 
table,  which  shall  serve  to  illustrate  the  mutual  dependence  between  the 
degree  of  .H.  aphakia  and  the  length  of  the  optical  axis,  I  have  started  with 
the  express  value  of  F.  The  value  of  f .  was  obtained  from  the  well  known 
formula,/,=^j~  and  according  to  which  this  table  has  been  estimated. 
On  these  values,  taking  into  consideration  the  distance  of  the  glass  from 
the  center  of  the  cornea  and  the  nodal  point  in  the  aphakic  eye,  the  values 
of  the  correcting  glass  and  the  aphakic  H.  are  dependent." 


TABI.E  X. 


383 


/„=Mm. 

^- 

//  acgtiisita. 

(Distance 
from  K=7  7.) 

Correcting  Glass  when 
Distance  from  Eye. 

R. 

Mm. 

p.  z. 

13.54  Mm.= 
0  5P- 

J0.31  Mm.=== 
05  P. 

30.61 

00 

CO 

1 

00 

0 

0 

1 
2.5 

2'J.m 

(549.1)2 

24 

1 
23.65 

1 

•24.5 

1 

24.75 

3 

28.58 

324.(55 

12 

11.65 

1 

ia.5 

1 
12.75 

1 
3.5 

27.24 

21(5.(54 

8 

1 
7.65 

1 

8.5 

1 

8.75 

_         1 
4.0 

2(5.81 

1(53.48 

« 

1 
5.65 

1 
6.5 

1 
6.75 

1 
5.7 

20.1(5 

135.30 

5 

1 
4.65 

1 
5.5 

1 
5.75 

1 
6.4 

25.75 

121.8(5 

4.5 

1 
4.15 

1 

5 

1 

5.25 

_         1 
7.6 

25.25 

108.32 

4 

1 
3.65 

1 
4.5 

.J 
1 

4.75 

_         1 
10.0 

24.(53 

04.78 

3.5 

1 
3.15 

1 
,4 

1' 
4.25 

_         1 
1.75 

23.8(5 

81.24 

3 

ITto 

1 
3.5 

3.75 

1     . 
00 

23.40 

74.47 

2.75 

1I40 

1 

3.25 

35 

27.7 

22.87 

67.47 

2.5 

Tl5 

3, 

111 

3.25 

+     ,     1 
.  12.0 

22.24 

(50.i»3 

2.25 

1 
1.90 

2.75 

1 
3 

-     -7V 

21.51 

54.16 

2.0 

1 
1.56 

1 
2.5 

1 
2.75 

4.6 

The  last  column  of  figures  requires  an  explanation.  It  is  desic^nated 
IJ.  (refraction).  The  reciprocal  values  which  th(?y  represent  are,  according 
to  Zehender's  suggestion,  the  various  grades  of  iiypermetropia  where  they 
are  minus,  and  the  various  grades  of  myopia  when  they  are  positive,  and 
emmetropia  is  designated  by  1.  All  these  values  have  been  estimated  ac- 
cording to  the  formula:  f^  —  F,=    /<  '''><      0.   Helmholtz,  1.  p.  49,  7*, 

fii  —  ■f'  II  r  } 

Since  f, — P.  represents  the  difference  of  position  between  the  retina 
of  the  emmetropic  and  the  ametropic  eye,  lience  it  became  necessaiy  in  the 
foregoing  paragi-aph  to  determine  for  the  emmetropic  eye  the  length  of 
its  axis,  and  for  this  reason  it  was  given  in  the  one  table  as  23.86  mm." 

"As  a  matter  of  course,  this  table  only  contains  the  average  values. 
A  comparison  of  this  table  with  the  foregoing  one  will  serve  to  clear  up  all 
the  causes  of  all  individual  differences." 


384 

ACCOMMODATION  OF  THE  APHAKIC  EYE.  "The  eye  does 
not  desist  from  making  accommodation  efforts  after  the  loss  of  the  lens. 
The  subjective  sensation  of  accommodative  effort  on  which  Bonders,  and 
so  correctly,  lays  such  great  stress,  is  very  evidently  present.  Not  only  do 
patients  who  have  been  operated  on  one  eye  or  both,  without  any  knowl- 
edge of  the  subject,  express  themselves  very  plainly,  stating,  that  notwith- 
standing every  effort,  they  are  not  al)le  to  see;  but  in  those  cases  where 
the  one  eye  is  aphakic  while  the  other  is  still  in  possession  of  its  accommo- 
dation, intelligent  patients  state,  that  they  are  made  aware  of  the  well- 
known  sensation  in  the  operated  eye." 

"Under  like  conditions,  in  cases  where  no  iridectomie  has  been  made. 
and  in  which  no  muscular  insufficiency  is  present,  the  aphakic  eye  will 
follow  the  accommodative  effort  of  the  other  eye,  by  making  the  corre- 
spondent movement  of  convergence,  and  likewise  the  pupil  will  undergo 
contraction  or  dilation.  Hence,  there  can  be  no  doubt,  that  in  both  eyes 
the  muscle  of  accommodation  has  a  similar  innervation,  and  is  likewise 
incited  to  contract.  This  view  is  further  strengthened  by  a  series  of  patho- 
logical experiences  which  have  already  been  referred  to.  These  accommo- 
dative efforts,  however,  have  no  result.  WitJi.  the  lo.'^s  of  the  lens  everj/  trace 
of  accommodative  power  passes  away.  Bonders  has  given  us  the  proof  of 
this  axiom." 

1.  "A  youthful  individual  was  successfully  operated  on  both  eyes  for 
congevifnl  caiaract.  By  using  glasses  ^  (+7.5  D),  5"  from  the  eye.  he 
saw  a  luminous  point,  perfectly  round  and  sharply  defined.  A  screen 
was  placed  between  the  one  eye  and  the  luminous  point,  and  now 
in  converging  so  as  to  cause  the  visual  axis  of  both  eyes  to  be  directed 
to  this  screen,  this  luminous  point  still  appeared  unchanged,  or  at 
most  somewhat  smaller  and  more  sharply  defined.  If  now  this  lens  before 
the  eye  was  only  moved  forward,  (10  mm.),  this  luminous  point  in 
distance  ceased  to  be  so  shaiTily  defined,  and  seemed  to  be  elongated  in  the 
opposite, direction.  This  visual  line  became  slightly  shorter  on  converging, 
without,  however,  becoming  merged  into  a  single  point.  This  shortening, 
as  well  as  the  diminution  in  size  of  the  point  which  had  been  so  sharply 
defined,  seemed  to  depend  on  the  narrowing  of  the  pupil  during  the  act 
of  convergence.  2.  In  a  second  cataract  operation, made  on  a  very  intelligent 
young  man,  Bonders  Avas  further  enabled  to  determine,  that  Avhere  a  point 
of  light  could  be  sharply  seon  by  using  a  certain  lens,  the  addition  of  n  lens 
of  light  could  be  sharply  seen  by  using  a  certain  lens,  the  addition  of  alensof 
+_j^or  — y^  would  materially  change  1he  sbariinoss  of  the  image.  In  a 
third  cage  this  difference  was  noticeable  on  the  addition  of  a  +  ■o"i7-  I'^" 
variably  the  patients  state,  by  the  addition  of  a  +^-^,  the  image  becomes 


385 
drawn  out  vertically,  nnd  by  the  use  of  a  —jl^  in  the  liorizoiital  diroetion. 
Whereas,  by  conver^in«i-  of  the  visual  line  in  making  his  experiment,  so  as 
to  see  near,  was  not  followed  by  tlif  slightest  effect  on  the  form  of  the 
images.  If  one  will  make  an  t'xaet  examination  of  the  amount  of  vision 
(V=0)  in  an  ai)hakic  eye,  foi-  some  pai'ticidar  point,  for  which  the  eye  is 
ec^uipped  with  a  certain  glass,  and  will  then  further  examine  the  anunint 
of  vision  which  the  eye  possesses  for  point>  lying  either  in  front  of  or  be- 
hind the  selected  point,  one  will  find  the  vision  becomes  reduced  in  botii 
directions.  From  thi-  it  must  follow,  that  the  eye  does  not  possess  any 
accommodation,  for  if  it  did  the  amount  of  vision  would  either  remain  the 
same,  or  in  cases  of  ])ositive  accommodation,  owing  to  the  object  being 
brought  closer  to  the  eye,  and  the  moving  forward  of  the  second  nodal 
point,  even  became  somewhat  greater  (Coert  over  de  scynbare  accommo- 
datie  by  aphakic).  The  truth  of  these  experiments,  undertaken  at  the 
suggestion  of  Bonders,  became  all  tlie  greater,  since  it  was  furtlier  shown 
that  the  circles  of  dispersion,  the  pupils  being  of  equal  size,  b'^came  larger 
instead  of  smaller  in  cases  in  which  there  was  an  aphakic  dioptric  system." 

"During  the  previous  century,  this  question  of  the  reeommodation  of  the 
aphakic  eye  (see  Bonders,  1526)  was  the  subject  of  vei'y  extensive  investigations, 
carried  on  especially  by  English  physicians  and  investigators  in  natural  sciences. 
Hunter  attempted  to  prove  the  correctness  of  the  tiieory  which  had  been  ac- 
cepted since  the  time  of  Leeuwenhoek.  namely,  that  tlie  lens  was  made  up  of 
muscular  fibres,  and  that  by  means  of  their  contraction  and  relaxation  we  were 
enabled  to  accommodate  for  various  distances.  His  successor.  Home,  hit  upon 
the  lucky  idea  of  deciding  this  question  of  accommodation  by  making  his  inves- 
tigations on  the  aphakic  eye.  In  this  work  he  sought  the  assistance  of  Rams- 
den,  and  both  came  to  the  conclusion  that  even  without  a  crystalline  lens  there 
existed  considerable  accommodation.  They,  however,  made  no  further  investi- 
gations after  they  found  that  Benjamin  Clark,  who  had  been  operated  on  for 
cataract,  and  on  whom  they  made  their  investigations,  could  read  at  different 
distances  with  the  same  glass.  Home  tiit-u  (•(inecivcd  the  idea  th;it  the  cornea 
changed  its  form  during  the  act  of  acconiniodatidu.  In  investigations  made  in 
this  direction,  they  distinctly  saw  tlie  cornea  advance  further  forward,  and 
from  this  they  concluded  that  tlie  coi-iiea  became  more  convex  on  accommo- 
dating for  near.  On  November  27.  isoo.  Thomas  Young  appeared  before  the 
Royal  Society,  and  ()pi>()sed  botli  of  these  statements  of  IlamsdcMi  .-iiid  Home, 
and  proved  in  the  most  convincing  manner  lliat  in  seeing  near  ol).iects  neitlier 
the  cornea  became  more  convex  nor  did  the  visual  axis  become  elongated,  and 
aside  from  this  he  proved,  not  only  by  exclusion,  but  by  the  most  positive  facts, 
that  the  seat  of  accommodation  could  only  be  found  in  the  lens  itself. 

"Assisted  by  his   friend  Ware,   he  likewise  examined  a   series  of  cases  of 
aphakia.     In  doing  tliis  lie  employed  I'orterfield's  optomc^ter.  wliicli  is  based  on 


386 

the  principle  of  Sclieiner's  experiments,  and  lie  convinced  himself  that  the  points 
of  intersection  of  the  threads  across  the  image  always  are  seen  exactly  in  the 
same  position.  Wherever  a  slight  difference  occurred,  he  could  always  find 
that  a  corresponding  change  in  distance  between  the  eye  and  the  glass 
was  to  blame.  Young  further  found  that  in  making  the  Scheiner's  experiment, 
if  small  objects  were  seen  double  the  patients  were  not  able,  by  exerting  any 
degree  of  effort,  to  bring  the  objects  closer  together.  Though  he  stated  that 
his  results  were  only  "tolerably  satisfactory,"  nevertheless  this  seems  really 
to  have  settled  the  question.  It  is  a  well  known  fact  that  these  investigations 
of  Thomas  Young,  "On  the  Mechanism  of  the  Ej^e,"  had  long  been  forgotten; 
hence,  it  can  not  be  so  much  of  a  surprise  to  find  such  men  as  Arlt  and  others 
ascribing  to  the  aphakic  eye  a  slight  degree  of  power  to  adapt  itself  to  various 
distances.  The  question  again  became  an  important  one  after  Kramer,  in  1852, 
had  given  us  the  direct  proof  that  the  lens  becomes  more  convex  during  the 
act  of  accommodation.  Since  it  was  exceedingly  difficult  to  prove  that  these 
images  on  the  lens  diminished  in  size  to  a  degree  proportionate  to  the  extent  of 
accommodation  as  measured  by  the  optometer,  hence  they  tried  to  positively 
settle  the  question  by  determining  whetlier  a  trace  of  accommodation  still  re- 
mained after  loss  of  the  crystalline  lens.  The  first  investigations  made  in  this 
direction  by  Von  Graefe  did  not  clear  up  this  subject.  (Beobachtungen  uber  die 
Accommodation  bei  Linsen  defect  u.  s.  w.  Arch,  fur  Opthal.,  II,  1.  p.  187.  1855). 
Graefe  verified  Ramsden's  expei'iments.  "Only  lately  I  examined  a  patient  who 
had  undergone  an  operation  for  cataract  on  both  eyes  but  four  weeks  previously, 
and  he  could  read  medium  sized  print  (No.  77  Yager's  test  types)  with  a  -|-3  con- 
vex, at  a  distance  of  6"  to  20".  But  since  only  a  short  time  previous  to  this  he 
himself  had  explained  why  eyes  with  high  degrees  of  hypermetropia  are  better 
able  to  distinguisli  small  objects,  notwithstanding  the  increased  size  of  the 
circles  of  dispersion,  when  they  bring  the  object  much  closer  to  the  eye:  hence, 
he  was  admonished  to  lie  careful,  and  thus  was  enabled  to  express  the  opinion, 
'that  shortly  after  a  cataract  operation  there  was  either  none  whatever  or  pos- 
sibly only  a  trace  of  accommodation  left.  And  where  he  says  that  the  amount 
of  adaptability  in  the  operated  eye,  as  compared  with  that  existing  under  nor- 
mal conditions  is  exceedingly  slight,  his  doubt  as  to  the  remnant  of  accommo- 
dation left  is  of  such  a  character,  that  he  sought  for  a  means  to  explain  this." 

"The  cause  for  these  unsatisfactory  results  was  owing  to  the  fact  that  the 
idea  of  'width  of  accommodation'  and  'amount  of  vision'  had  not  yet  been  so 
accurately  determined.  After  Helmholtz  liad  expressed  himself,  'in  order  to 
prove  that  accommodation  is  still  present,  the  patient  must  be  able  to  distin- 
guish an  object  at  a  given  distance  distinctly  or  indistinctly,  even  after  he  has 
attempted  to  see  an  object  at  the  same  or  at  a  greater  distance.'  it  still  re- 
mained for  Bonders  to  give  us  the  accui'ate  proof,  that  an  aphakic  eye  possessed 
absolutely  no  power  of  accommodation.  (See  text.)  Hence,  it  will  ho  a  matter 
of  the  greatest  surprise  to  learn  that  in  1872  Foerster  (Klin.  Monatl)liitt.  p.  39. 
Accommodations  verniogen  l)ei  .\plinkiel  expressed  liiiuself.  tliat  aceoiniiiDdation 


.^87 
was  present  in  eyes  devoid  of  a  lens.  Foersiei-  lias  iiotliiny  lurtlier  to  offer  us 
than  the  lIonie-TtaTusden  experiments,  and  he  even  iieKleeted  in  the  sinj?le  ease 
which  he  examined  to  make  an  accurate  test  of  I  lie  refract' on,  to  give  the  amount 
of  vision  for  distance,  the  size  of  the  test  type  used,  and  to  inform  us  whether 
or  not  care  was  taken  to  see  that  the  lenses  were  properly  centered,  so  as  to 
coincide  with  the  visual  axis.  Hence,  it  seemed  hardly  necessary  To  reply 
to  his  paper.  Nevertheless,  it  called  forfli  a  mass  of  refutations.  Mannhard  re- 
i-t'i)c:itiMl  !{;ins(len"s  cxpcriiiiciiis.  usiii^i  the  Siieilcii  test  lyiie  and  P.urghardt's 
dotted  tests.  Tlie  more  delicate  tlie  oli.jcct  used  tlie  more  delicate  these  tests 
for  amount  of  vision  and  (lis(ance  became:  tlie  more  this  apparent  width  of  ac- 
commodation shrank  together.  I  Avas  enabled  to  get  the  same  mentioned  col- 
league and  make  these  experiments  on  him,  and  I  also  used  the  rodoptometer, 
the  apparent  width  of  accommodation  equaled  with  -f-i/^  and  Sn  No.  1%  about 
2*0.  with  Hurgliardfs  dotted  tests  No.  3,  less  than  .}^  and  with  tlie  rodopto- 
meter. less  than  ^i^  The  use  of  this  rodoptometer,  which  was  not  used  by 
Foerster.  appears  to  me  to  be  the  most  conclusive  of  all  the  tests  for  vision. 
Above  all.  to  make  these  tests  properly,  the  patient  should  be  a  scientifically 
educated  as  well  as  an  honest  man.  Above  I  have  already  mentioned  the  in- 
vestigations of  Coert,  made  under  the  supervision  of  Bonders.  Woinow  sided 
with  Foerster  to  a  certain  degree.  He  placed  a  piece  of  cobalt  glass  in  a  slit 
and  illuminated  this  from  the  rear,  and  then  found  that  in  his  own  atroi)ized 
eye.  simply  moving  the  instrument  2-3  mm.  nearer  to  his  eye  was  sufficient  to 
cause  the  edges  of  the  split  to  be  bordered  with  colors.  He  however  found  that 
those  who  had  undergone  cataract  operation  could  see  this  slit  at  a  more  vari- 
able distance  without  the  appearance  of  this  border,  so  that  in  intelligent  pa- 
tients with  a  vision  equal  to  or  less  than  two-thirds,  he  could  find  a  remnant  of 
accommodation  of  about  ^l. 

THE  ACITTENESS  OF  VISION  IN  APHAKIA.  ^'Strictly  speak- 
ing, every  cataract  operation  has  attained  an  optical  result,  in  which  vision 
is  better  after,  than  it  was  before  an  operation."  Eor  example,  if  fingers 
could  no  longer  be  counted  before  the  operation,  and  if  this  has  become 
possible  afterward;  or  if  fingers  can  be  counted  at  a  greater  distance  than 
before  the  operation,  one  surely  would  not  say  that  the  eyesight  has  not 
been  improved  by  the  operation.  However,  neither  patient  nor  physician 
would  be  satisfied  with  such  a  result.  Both  have  acceded  to  the  operation 
with  the  hope,  that  a  useful  degree  of  vision  would  be  restored,  and  only 
if  this  is  attained,  as  compared  with  an  insufficient  or  partial  restoration, 
can  one  speak  of  a  satisfactory  result." 

"Since  one  meets  with  every  degree  of  vision,  from  counting  of  fingers 
up  to  |§.  hence  repeatedly  in  compiling  statistics,  the  want  of  a  sharp 
line  to  guide  onr  rcstilts  has  made  itself  ai)])arcnt:  but  sueli  docs  not 
exist.  In  special  cases  this  depends  entirely  on  the  requiretnents  which  the 
patient  demands  from  his  eyes." 


388 

"But  seldom  does  the  acuteness  of  vision  of  the  aphakic  eye  equal 
that  of  the  normal  eye.  This  is  determined  by  the  Snellen  type,  always, 
however,  bearing  in  mind  the  age  of  the  patient.  Howevor,  as  Bonders 
pointed  out,  owing  to  the  magnifying  power  of  the  cataract  glasses,  we 
must  make  a  slight  correction." 

"Owing  to  the  fact,  that  either  convex  glasses  of  varying  strength  are 
required  to  see  at  the  various  distances,  or  the  glasses  must  be  adjusted  at 
varying  distances  from  the  eye;  hence,  the  acuity  of  vision,  where  this  is 
simply  determined  by  convex  glasses,  will  show  great  differences  for  the 
various  distances.  Equal  values  can  only  be  attained,  if  one  will  multiply 
these  with  the  corresponding  so-called  (verkleinerungs  zahlen)  reduced 
figures." 

"If  we  will  now  consider  those  cases  of  aphakia  which  have  been  cor- 
rected for  distance  by  spherical  glasses,  we  must  look  upon  the  attainment 
of  an  acuity  of  vision  of  20-70  as  the  average  amount  following  a  successful 
cataract  operation.  But  in  many  cases  y=^%  or  ,Yff  ^^^  distance,  an- 
swers all  requirements,  which  are  needed  for  near  work.  If  one  will  no-w 
classify  the  results  following  the  operation  into  losses,  partial  and  total  good 
results,  we  must  look  upon  all  as  belonging  to  the  first  class,  in  which  vision 
is  less  than  iV  at  twenty  feet.  And  all  belong  to  the  third  class,  in  which 
vision  is  <tu" 

Knapp  states:  "Consiaering  V  ^j^^  to  |§  as  a  good  result,  5V0  to  jij  as  a 
moderate  result,  mere  perception  of  light  and  blindness  as  failure,  the  visual  re- 
sults in  1,000  successive  cases.  186G-1888.  Avere.  good  8.5.4  per  cent.,  moderate 
8.3  per  cent.,  failure  6.3  per  cent.;  loss  from  suppuration  4.2  per  cent.,  loss  from 
all  causes  2.1  per  cent. 

From  June  10,  1886,  to  June,  1897,  I  have  practiced  the  simple  extrac- 
tion as  a  rule.  In  300  simple  extractions,  good.  9(5.33  per  cent.;  moderate, 
2.06  per  cent.;  failure,  1.01  per  cent.^ 

"Those  cases  deserve  especial  attention  in  which  V=ig.  Such  a  result  is 
entirely  wanting  in  Knapp's  and  Snellen's  cases,  the  former  having  but  one 
case  in  which  vision  reached  %,  and  the  latter  but  six  cases  in  which  vision 
equaled  1/2,  but  in  not  a  single  case  did  vision  equal  1.  Compared  with  these 
statements,  I  wish  to  mention  one  made  by  Weber,  who  passingly  (1117,  p.  190) 
says,  that  according  to  the  method  employed  at  present,  lianlly  in  '/^of  the  cases 
does  vision  equal  1.  Such  a  statement  is  hard  to  understand,  unless  one  as- 
sumes, that  he  determined  vision  in  a  manner  entirely  different  from  the  method 
laid  down." 

CAUSES  FOK  THE  I)nilXL:Tl()X  OF  THE  ACL'ITY  OF  VISION! 
IN  APHAKIA  ASTYGMATISM  AS    A  KESULT  OF    THE    OPEHA- 

aNorris  and  Oliver.    System  of  1  >ise:ises  of  tl>e  Eye.     \(.l.  III.,  pa.ire  818. 


389 

TTON.  'IMial  noniial  vision,  jiccoi'dinii'  lo  llic  Snellen  iden,  is  so  seldom 
attained  iil'ter  a  cataract  operation.  >o  lon^'  as  we  coiiline  ourselves  to  the 
use  of  sjiherical  fjlasscs.  vieniands  an  ex])lanation,  especially  since  Weber 
has  definitely  stated  that  "tlie  moving-  I'oi'ward  of  the  nodal  ])oints.  should 
justify  us  in  theoretically  e.\pectin<i-  an  acuity  of  \i>ion  much  <,M-eater  than 
normal,  after  a  catai'act   o])eration.'  " 

"Let  us  only  considei-  the  senile  cataract,  and  we  will  tiiul  one  cause 
for  this  at  once  in  the  fact,  that  according  to  the  investigations  of  DeHaan, 
in  the  sixtieth  year  vision  sinks  to  |-J;  that  is,  to  -^.  Aside  from  this 
opacities  in  the  ]iii])illary  area  are  su])posed  to  be  the  main  cause  of  the 
reduction  in  the  vision.  Sui'ely  we  have  already  dwelt  sufficiently  on  the 
fact  that  even  in  cases  of  simple  secondary  cataract,  the  folds  in  the  cap- 
sule, and  the  slight  cloudy  spots  in  the  same,  give  us  the  anatomical  basis 
lor  the  increased  reflection  and  dispersion  of  light.  In  consequence  of  this, 
not  only  are  the  retinal  images  less  brightly  illuminated,  but  likewise,  as  a 
result  of  the  dispersion  of  light,  the  images  are  less  shar]dy  defined.  The 
influence  of  a  secondaiy  cataract, becomes  most  evident, for  in  cases  of  a  very 
dense  secondary  cataract,  vision  may  be  exceedingly  good,  if  there  is  but  a 
small  opening,  and  at  times  this  is  proven  by  the  extraordinary  influence 
which  a  discission  of  a  secondary  cataract  exerts  on  vision.  But  even  after 
such  a.  procedure,  or  after  the  extraction  of  a  cataract  in  its  capsule,  even 
after  making  a  vitreous  puncture,  we  but  seldom  attain  a  result  in  which 
vision  equals  ||.  Since  the  curvature  of  the  surface  which  separates 
the  vitreous  from  the  aqueous  has  no  influence  on  the  sharpness  of  the 
retinal  images,  and  since  an  immovable  pupil  or  even  a  large  coloboma  (at 
least  as  it  is  associated  with  direct  seeing)  is  without  influence  on  the 
acuity  of  vision,  hence  the  main  cause  for  the  diminution  of  vision  in  the 
successful  cases  of  cataract  operation  must  be  sought  in  ihe  rhnnried  ciirva- 
tvre  of  the  cornea,  which  is  the  most  important  of  all  the  refractive  sur- 
faces." 

'■Ponders  (Enjr.  Edit..  1864.  p.  315)  in  1864  drew  attf-ntion  to  this  fact.  It 
appears  tliat  .Taval  (Klin.  Mouatsblatt.,  1865.  p.  339)  was  the  first  to  really 
measure  the  amount  of  astyyinatism  in  those  who  had  underj^ono  cataract 
operation.  In  one  case,  by  usinjj  a  cylinder  of  ,'„.  the  acuity  of  vision 
was  increased  from  %  to  ^:  whereas,  by  the  most  careful  selection  of  a  proper 
spherical  glass,  this  could  only  be  increased  to  H>.  Oraefe  likewise  expressed 
himself,  that  the  cause  of  this  astygmatism  which  appears  after  cataract,  oper- 
ations in  a  good  many  eases,  is  due  to  a  less  perfect  cicatrization,  which  leads 
to  this  cylindrical  curvature  of  the  cornea.  But  if  vision  was  normal  before 
the  formation  of  the  cataract,  and  if  after  tlie  operation  vision  is  very  materi- 
ally improved  by  the  use  of  a  cylindrical  glass,  this  could  be  explained  by  as- 


390 

suming  that  in  the  former  integrity  of  the  lens  system  the  degree  of  corneal 
and  lens  astygmatism  exactly  compensated  each  other,  and  later  on  when 
aphakia  had  set  in.  the  corneal  astygmatism  still  remained.  Whereas,  in  such 
cases  tlie  conditions  remain  totally  stabil;  still,  under  the  first  named  condi- 
tions these  gradually  become  changed  to  the  advantage  of  ihe  patient.  Haase 
(Wiesbaden  Klin.  Beobachtungen.  III.  p.  IKJt  then  more  fully  examined  into 
the  causation  of  this  astygmatism  which  develops  after  cataract  operations. 
He  found  that  in  cases  in  Avhich  the  incision  was  made  exactly  in  the  hori- 
zontal meridian,  one  would  always  find  the  meridian  which  refracts  most 
strongly  exactly  horizontal.  If  the  direction  of  the  incision  was  slightly  changed, 
then  likewise  also  the  direction  of  the  most  strongly  refracting  meridian.  Dur- 
ing the  process  of  healing  of  a  flap  incision,  the  intra-ocular  pressure  will  con- 
stantly press  the  edge  of  the  wound,  which  still  gives  apart.  By  this  means  the 
curvature  of  the  cornea  becomes  flattened  in  its  vertical  meridian;  whereas,  the 
curvature  of  its  horizontal  meridian  will  be  increased.  In  cases  of  abnormal 
healing,  as  in  prolapsus  iridis,  the  astygmatism  is  so  irregular  that  a  good  cor- 
rection can  not  be  obtained  by  use  of  cylinders.  In  the  six  cases  of  flap  extrac- 
tion which  he  reports,  the  astygmatism  varied  from  Ye  to  % ." 

'•Eeus  and  Woiiiow  (1167)  have  collected  the  largest  amount  of  ma- 
terial having  a  bearing  on  this  subject.  They  were  enabled  to  make  opthal- 
mometric  examinations  in  thirty-one  patients  who  had  been  operated  for 
cataracts.  Of  these  twenty-three  had  been  measured  before  the  operation. 
From  this  they  were  enabled  to  determine  how  much  of  the  astygmatism 
had  developed  in  consequence  of  the  operation.  If  we  will  now  consider 
those  twelve  cases  (1,  3,  5,  8,  10,  13,  15,  17,  18,  24,  28  and  31)  in  wliieh 
the  principal  meridian  was  exactly  vertical  and  horizontal,  both  before  and 
after  the  operation,  we  find  in  only  eleven  cases  an  increase  in  the  curva- 
ture; that  is,  a  shortening  of  the  corneal  radius  in  the  horizontal,  and  only 
in  ten  cases  is  there  a  diminution  of  curvature;  that  is,  an  increase  of  the 
corneal  radius  in  the  vertical  meridian.  In  the  other  cases  the  result  was 
directly  opposite.  And  in  fact,  both  forms 'occur  as  well  after  flap  ex- 
tractions as  after  the  corneal  extraction." 

"Hence,  it  seems  quite  evident  that  the  degree  of  astygmatism  after 
an  operation  depends  very  materially  on  the  degree  present  before  the 
operation,  and  also  on  the  direction  of  the  same.  One  can  not, 
however,  in  any  given  case,  determine  from  the  degree  of  astygmatism  pres- 
ent after  an  operation  wliich  method  of  operation  would  have  given  the 
best  result." 

"This  much,  however,  is  certain,  that  in  the  twelve  mentioned  cases, 
the  particular  condition  was  produced  by  the  operation.  Reuss  is  very 
careful  in  making  his  statement,  and  merely  says,  that  the  astygmatism 
is  caused  by  the  cicatrix,  and  its  degree  is  largely  dependent  on  the  more 


391 
or  less  perfect  processes  of  lu'iilin>i-.  More  cxactlv  stated,  always  depend- 
ent on  the  kind  of  astyjrniatism  present  Ix't'orr  tlir  opei'aiion.  The  direc- 
tion of  the  aecpiired  astygniatisni  is  always  (Icpeiidcnt  on  the  position  of 
the  incision,  its  extent,  on  the  perfect  liealin-.  and  it>  n-iilarity  dei)ends 
on  wliether  or  no!  tlie  iris  and  capsule  Ixn-onie  cicatrized  in  the  wound." 

"Althoii.ali   we  must  aeknowled^a'  tiiat    we  do  not  as  yet  possess  any 
positive  amitoniical  exjdanations  for  those  cases  in  which  the  vertical  me- 
ridian has  an  increased  curvature,  and  the  horizo'ital  a  diminished  curva- 
ture after  the  operation;  nevertlieless,  in  all  of  the  ihii1y-one  eases  nu'as- 
iired  hy  Eeuss  and  Woinow  the  corneal  astygniatism  was  changed  as  the 
result  of  the  operation.     Hence,  Eeuss  is  correct  when  he  considers  the 
above  second  explanation   of  Yon  Graefe  as  only  correct  for  those  eyes 
which  were  operated  hy  discission  or  reclination,  hut  not  for  those  in  which 
the  lens  was  removed  from  the  eye  hy  an  excision.     jSTow,  in  wdiat  manner 
does  this  cicatrix  bring  about  this  acquired  astygmatism?   Concerning  this 
point,  up  to  the  present  time  there  have  existed  but  suppositions.     After 
such  data  as  can  be  gleaned  from  our  knowledge  concerning  the  cicatrix 
following  cataract  extraction,  and  according  to  the  facts  which  have  been 
^iven  us  as  a  result  of  the  experimental  investigations  of  Gussenbauer  and 
Guterboek,  there  can  scarcely  arise  any  question  as  to  the  influence  of  an 
intercalar  substance  in  cases  of  perfect  cicatrization,  since  this  was  found 
to  be  but  0.02  mm.  in  width.    However,  the  inelosi;re  of  foreign  substance, 
especially    of    the    capsule    or    the    iris,    where    this    has    taken    place 
to.  a  large  degree,  must  exert  an  influence  on  the  conditions  of  curvature 
of  the  cornea.     Even  in  cases  in  which  a  perfect  cicatrization  has  taken 
place,  it  does  occur  that  the  lip  of  the  corneal  wound  becomes  displaced 
toward  the  sclera,  and  in  five  cases  I  (Becker)  have  been  able  to  measure 
this  exactly.     This  varied  from  0.12  mm.  to  0.3  mm.     It  appears  (if  the 
number  of  these  observations  can  be  looked  upon  as  sufficient  from  which 
to  draw  conclusions)  i  o  be  larger  after  flap  extraction,  ceteris  paribus,  than 
after  the  scleral  extraction,  and  aside  from  this  is  favored  by  the  enclosure 
of  foreign  substance  in  the  cicatrical  tissue.     And  finally  I  (Becker)  was 
enabled  to  prove  that  the  portions  of  corneal  and  scleral  tissue  close  to 
the  cicatrix  were  very  much  increased  in  thickness,  in  abnormal  cases  as 
much  as  0.5  mm.    Beyond  a  doubt -this  is  due  to  infiltration  and  oedematous 
swelling  of  the  tissue,  and  hence  can  not  be  considered  as  an  increase  in 
the  amount  of  tissue  laid  down  in  the  direction  of  the  corneal  lamellae, 
that  is  perpendicular  to  the  direction  of  the  wound,  without  a  simultaneous 
swelling  being  present."' 

"We  must,  however,  call  attention  to  another  factor  which  gives  rise 
to  change  in  the  corneal  curvature.    The  clinician,  and  rightly,  too.  knows 


392 

but  too  well  thai  tlie  drawing  in  of  the  extraction  cicatrix  is  but  a  much- 
feared  symptom  of  beginning  phthisis  bulbi.  Aside  from  this  I  have  re- 
peatedly drawn  attention  to  the  great  tension  which  the  contraction  of 
secondary  cataracts,  which  have  cicatrized  in  the  wounds,  exert  while 
shrinking,  on  the  corpus  ciliare,  the  vitreous,  etc.  Now,  there  can  be  no 
doubt  but  that  even  where  this  exists  to  a  slight  degree  in  eyes  which  can 
see,  the  shrinking  of  this  secondary  cataract  by  its  tension  will  draw  the 
cornea  backward.  By  this  means  the  curvature  of  the  cornea  will  become 
increased  vertically  to  the  direction  of  the  incision;  and  hence,  the  cornea 
is  given  a  more  cylindrical  shape,  and  the  curvature  of  the  horizontal  me- 
ridian will  become  diminished." 

"For  the  present  I  must  leave  unanswered  the  question  as  to  whether 
this  tension  of  a  secondary  cataract  can  act  in  just  the  opposite  way,  caus- 
ing an  increase  of  the  horizontal  and  a  diminution  of  the  vertical  meridian." 
"This  influence,  which  the  various  methods  of  cicatrization  of  wound 
exerts  on  the  condition  of  the  curvature  of  the  cornea,  must  be  entirely 
diiferent,  and  makes  its  effect  felt  in  just  the  opposite  way  where  the  in- 
cision is  made  vertically  or  obliquely.  The  pushing  more  anteriorly  of  the 
edge  of  the  corneal  wound  must  necessarily  have  as  its  result  a  diminution 
of  the  curvature  of  the  cornea,  vertical  to  the  direction  of  the  wound.  But 
if  no  sliding  past  each  other  of  the  edges  of  the  wound  has  taken  place, 
and  if  one  can  everywhere  see  the  scleral  edge  of  the  wound  and  the  under- 
lying edge  of  the  cornea,  the  swelling  of  the  substance  which  hes  between 
the  edges  of  the  wound,  must  cause  the  increase  in  the  curvature  of  the 
cornea  in  the  vertical  meridian.  For  if  we  attempt  to  introduce  the  seg- 
ment of  a  circle  between  two  fixed  points  of  a  segment, of  another  circle, 
this  can  only  be  accomplished  by  increasing  the  radius  of  curvature  of 
the  latter." 

"The  action  of  a  connective  tissue  mass  between  the  edges  of  the 
wound  acts  differently,  depending  on  whether  a  sliding  past  each  other 
of  the  edges  of  the  wound  has  taken  place  or  not.  If  the  outer  edges  of 
the  w^ound  are  in  exact  apposition,  owing  to  the  presence  of  this  connect- 
ive tissue  mass,  the  curvature  likewise  must  become  greater.  If  at  the 
same  time  this  mass  causes  a  forw'ard  displacement  of  the  edges  of  the 
wound,  this  flattening  action  of  the  cicatrix  must  be  increased.  If  the 
incision  is  made  perpendicular  to  the  surface  of  the  cornea,  as  it  is  in  the 
ideal  Cxraefe's  extraction,  such  a  displacement  forward  can  not  occiu*  so 
easily,  and  therefore  is  not  so  frequently  obsei-ved  as  after  the  flap  extrac- 
tion, in  which  the  incision  is  made  perpendicular  to  the  visual  line.  In 
the  flap  operation  there  is  a  greater  tendency  for  the  edges  of  tlic  wound 
to  gaj).  and  this  is  in  accord  with  the  greater  frequeiu-y  and  the  greater 


393 

degree  of  disphuonu'iit  forward.  Jlased  on  measurements  made  l)y  me,  the 
amount  of  flattening  which  the  cornea  siifl'ers  as  a  result  of  displacement 
after  fia])  extraction  can  be  measured/" 

"vStartiuj:  out  with  the  assumption  that  the  ooruea  lias  a  sphorical  curva- 
ture, a  vertical  section  of  the  same  would  he  represented  by  the  segment  of  a 
circle,  the  chord  of  which  would  be  equal  to  the  distance  from  the  upper  to  the 
lower  edge  of  the  cornea.  The  length  of  this  seguient  is  calculated  by  the  for- 
mula: '^^"i'".  when  n°  is  eciual  to  the  angle  which  tlie  segment  of  the 
360°  ' 

circle  subtends,  the  radius  (R.)— 7.7  mm.,  and  the  distance  from  the  upper  to 
the  lower  edge  of  the  cornea  equals  10  mm.,  then  the  length  of  this  segment  of 
the  circle  (P.)  equals  10.8834  mm." 

"The  direction  which  the  edge  of  the  corneal  wound  takes  as  it  moves 
forward,  is  determined  by  the  direction  of  the  original  incision.  If  this 
falls  in  that  of  the  ideal  linear  incision,  in  the  direction  of  its  greatest 
circle,  the  anterior  movement  will  take  place  in  a  line  that  is  along  the 
radius  drawn  from  the  center  of  the  circle  toward  the  upper  edge  of  the 
cornea.  The  segment  of  the  circle  will  remain  the  same,  but  the  chord 
which  it  subtends  will  have  grown  larger.  If  this  forward  movement  equals 
respectively,  0.12,  and  0.15,  and  0.3  mm.,  the  radius  will  be,  respectively, 
8.0798,  8.1TT-"),  and  8.7638  mm.  Starting  out  with  the  assumption  that 
previous  to  the  operation  both  the  vertical  and  the  horizontal  meridian 
had  a  radius  of  7.T  mm.,  they  will  now  have  a  radius  respestlvely  of  jf^, 
,  '_,    and    ^ L<  •     III  making  this  calculation,  the  further  hypothesis  was 

14.4/'  0.9t)4  ^  '  '  '■ 

drawn  that  this  flattening  of  the  corneal  surface  was  equally  distributed 
over  the  entire  vertical  meridian.  However,  in  doing  this  no  attention 
was  paid  to  the  fact,  and  the  same  was  done  in  the  calculation  of  Eeuss 
and  Woinow,  that  simultaneously  with  this  flattening  in  the  vertical 
meridian,  an  increased  curvature  manifests  itself  in  the  horizontal." 

"Notwithstanding  this,  the  calculations  of  Dr.  AVeiss  show,  that  the 
average  measurement  as  used  by  me  is  sufficient  to  explain  the  degree  of 
astygmatism  found  after  an  extraction.  This  increased  curvature  of  the 
horizontal  meridian,  which  for  the  time  had  been  neglected,  may  be  as- 
sumed to  correct  the  astygmatism  which  had  previously  existed  in  the 
opposite  direction." 

"Various  observers  have  noted,  that  the  astygmatism  wliicli  develops 
after  cataract  extraction  becomes  less  as  time  goes  on.  This  can  be  ex- 
plained anatomically  by  the  gradual  diminution  of  the  infiltration,  and 
swollen  conditions  of  the  area  surrounding  tlie  wound,  and  by  the  gradual 
contraction  to  a  smaller  volume  of  the  connective  tissue  mass  when  pres- 
ent, and  also  by  the  gradual  return  of  the  flap  to  its  normal  niveau,  where 
this  has  glided  i)ast  its  fellow,  owing  to  the  tense  drawing  together  of  the 


394 

interstitial  tissue.  This  can  not  be  absolutely  proven,  since  it  is  not  pos- 
sible to  make  anatomical  examinations  of  the  same  eye  at  various  periods. 
But  these  conclusions  are  justified,  and  may  be  as>uuied  to  be  facts,  as 
the  result  of  anatomical  examinations  of  various  eyes  made  at  different 
periods  after  operations.  Hence,  the  astygmatism  must  graduallx  diminish 
in  both  directions." 

•'I  (Becker)  owe  special  thanks  to  Dr.  Roder,  of  Strassbury-.  for  the  personal 
eomnnmication  of  a  case  which  clinically  is  of  the  very  greatest  interest.  He 
noted  that  the  astygmatism  following  an  operation  suddenly  became  less  after 
the. making  of  an  iridectomie  for  secondary  cataract.  The  horizontal  incision 
made  Avith  the  lance,  made  to  relieve  the  secondary  cataract,  must  for  the 
time  have  relieved  the  tension  which  this  exerted  at  the  sight  of  the  original 
wound.  Hence,  if  the  curvature  of  the  cornea  perpendicular  to  the  direction 
of  the  "incision  before  the  irdectomie  was  greater,  one  must  certainly  be  able 
to  see  that  the  cutting  through  of  the  capsule  would  have  released  and  equal- 
ized this;  but  since  likewise  a  less  degree  of  curvature  in  the  vertical  and  an 
increased  degree  in  the  horizontal  should  likewise  be  abolished  by  an  iridec- 
tomie. Ave  must  also  seek  part  of  the  explanation  for  this  in  the  vertical  in- 
cision of  the  capsule,  made  Avith  the  pinceciseaux.  But  since  this  fact  has 
not  as  yet  been  as  well  proven  as  could  be  desired,  it  would  hardly  seem  neces- 
sary to  seek  for  an  anatomical  basis  for  the  same  as  yet.  But  if  tiiis  should 
be  proven  to  be  true,  it  certainly  would  become  a  matter  of  vmusual  interest. 
There  Avould  then  ajtpear  to  be  a  way  in  Avhich  to  cure,  by  oi)erative  means, 
astygmatism  Avliicli  results  from  oiteration." 

"Although  tlie  measurements  of  Reuss  and  WoinoAV  made  on  the  living, 
and  my  (Becker)  measurements  made  on  anatomical  preimnjtion.  coincide  ex- 
actly Avith  the  results  obtained  by  Haase,  namely,  that  corneal  astygmatism  is 
greater  after  the  flap  extraction  than  aftei-  the  linear  extraotion.  one  must  never- 
theless be  careful  and  not  accept  this  as  an  absolutely  established  fact,  llaase 
undoubtedly  picked  out  the  most  pronounced  cases,  since  during  an  entire  year 
he  only  measured  the  astygmatism  in  six  cases  of  all  those  operated  by  Pagon- 
stecher;  whereas,  among  Reuss'  and  WoinoAv's  thirty-one  cases,  tliere  are  but 
live  flap  extractions,  and  of  tliese  but  in  tluec  cases  Avas  tlie  cornea  measui'ed 
before.      In   addition   to   this,    I    tind    tiial    the  greatest    degi-ee  of   astygmatism 

noted,  '         did  not  occur  after  a  flap  onei-ation.  but  .-iftcr  a  liuear  extraction. 

.T.n'i 
Nevertheless,    tlie   subject    is   certainly   deserving   of   every    cousiderMtiou,    and 

as  early  as  1S<;T  W'elier  drew  attention  to  the  fact,  liiai  the  various  operations 
exerted  a  varying  iufhieuce  on  tlie  inetliods  of  healing  and  the  sul>se(|uent  as- 
tygmatism. .\ii(l  it  c.-in  not  be  denied,  that  if  it  sliould  liually  lie  shown  rhat 
one  operation  is  more  I'csiKiusihle  for  this  couilitiou  than  die  dtlier.  this  factor 
Avould  certainly  weigh  heavy  in  tlie  lialaiice  against  it.  1  >r.  Weiss  has  lately 
taken  up  these  investigations  .-igaiii.  and  I  may  state,  that  live  cases  which 
Avere   measured   ])ef<)re  and   after   operation    by   the    Weber  s   inetliod.    in   three 


395 
cases  chanjro  iu  form  were  t<niii(l  iiftcr  tin-  optiiitiDii.  wiiidi  liad  an  nstygma- 
tisni   of  1:11.2.   ]:ir>.4,    1:L'T.:?:   wliciviis,   iu   two  cast's   wiiicli    ucro  f)|)«*nitt*d   by 

Weber,  the  astvjiniatisin  was  U  and  1 — .     Tlir  iiilliu'iicc  which  the  subse- 

^  9.(13 

quent  corivctiou  of  tlic  a<-(iuinHl  astyjiinatisni  followin^i  cataract  (>.vtraction  has 
on  the  acuity  of  vision  of  tiu'  a|)liakic  cyt'.  is  shown  by  tlic  followiufr  iuvt^sti- 
gations  of  Keuss  and  Woiuow.  In  twcnty-nino  ryi-s  which  wore  subjected  to 
a  thorough  examination  by  tlie  use  of  si)herical  glasses,  four  acquired  V=^ 
four  V --  ,y„,  thirteen.  V  rfj,  six.  V=  V^,  two,  V=  ?fj.  But  where  these 
same  eyes  were  corrected  l)y  ii  coinbinatimi  of  sjiherical  and  cylindrical 
glasses,  there  was  but  a  single  case  in  wliich  \'  j-',;,,  i.  wiiich  could  not  be 
improved.  In  the  others,  however,  vision  was  raised   four  times  to  V  =  |g, 

three  times  to  2j?  seven  times  to  f^  ten  times  to  fg  .^nfi  f„„r  times  to 
fg.  The  last  tigures  are  especially  interesting,  liecause  once  vision  of  ,2gOj, 
twice  vision  of  ?;|,   and  once  vision  of  ||;   was  raised  to  this  iiigli  degree." 

The  above  statements  liavc  been  verified  1)\  .Vdolpli  ().  Ffingst.  He 
draws  attention  to  the  literature  on  this  subject.  La([iier.2  ('hintemi,2a 
Bumett.3 

He  states:  "AVe  know  that  in  tbe  majority  of  cases  tlie  addition  of  a 
cylinder  to  the  spherical  lens  improves  the  vision.  As  the  cornea  grad- 
ually assumes  its  original  or  almost  original  shape  by  the  contraction  of 
the  cicatrix,  the  cylinder  glass  frequently  ceases  to  be  of  benefit.  To  avoid 
the  expense  of  a  new  glass  after  this  contraction  has  taken  place,  we  are, 
and  especially  in  hospital  practice,  often  called  upon  to  prescribe  at  once 
the  lens  which  we  consider  best  for  ultimate  use."  He  gives  the  following 
interesting;  tables: 


J.— CASES  WITH  COMPLICATED  HEALIXG  OE  WOI^XD. 

Extraction  of  Iridectomy.    W.  R.— with  the  Rule.    Ag.  R.— against  the  Rule. 


d 

Astig.  before 
operation. 

Astig.  2  wks. 
after  opera. 

Astig.  6-10    ;  Astig.  4-6     Astig.  6-10 
weeks  after       months         months 
operation,     afteropera.  afteropera 

1 

REMARKS. 

I 

1.0  D.  W.  R. 

9..S  D.  Ag.  R. 

6  weeks,  356  mon.,  2.5 
D.  ag.  R.          ag.  R 

Slight  incarceration  of  iris  in 
middle  of  section. 

2 

I.o  D.  W.  R. 

lO.O 

4^4   month. 
20  ag.  R. 

Iris  drawn  upward,  and  slight  a  d 
hesion  to  middle  of  section. 

3 

18.0 

Prolapse  of  iris,  abscised  14  hours 
later. 

4 

13.0 

Prolapse  of  small  head  of  vitreous. 
Small  incarceration  ot  iris. 

3 

1,75  D.  W.   R. 

12.0 

Patient  ruptured  wound  3  times. 
.\dhesion  of  iris  to  middle  of  sec. 

6 

'"•"  • 

6  weeks.  1.90 
ag.  R. 

Large  incarceration  of  iris  in  mid- 
dle of  section. 

7 

0.75  D.  Ag.  R. 

6.0 

8  weeks.    6.5 
ag.  R. 

Prolapse  of  iris,  abscised  8  hours 
later. 

8 

0.5  D.  W.  R. 

12  0 

Iris  adherent  to  middle  of  section. 

9 

22.0 

Iris  adherent  to  section  in  its 
entire  extent. 

lo 

0.5  D.  W.  R, 

1 

Incarceration  of  column  or  iris  in 

11 

7.0 

6  month  6.oi 
ag.  R.        j 

wound,  on  nasal  side. 
Prolapse  of  iris,  ab.scised  12  hours 

12.0          •' 

1 

later. 

12 

i 

Adhesion  of  iris  in  entire  length 

17.0 

of  wound. 

155-5 

Average,  12.9  D. 

2  Arch,  fur  Opthalmol.,  XXX..  1884. 
2a  Annales  di  Ottal.,  1890. 

3  A  Treatise  on  Astygmatism.  p.  120. 


396 


B.— CASES  AVITH  UNCOMPLICATED  HEALING  OF  WOUND. 


No. 

Astig. 

Before 

Operation. 

Two  Weeks 

After 
Operation. 

6-10  Weeks 
After  Operation. 

4-6  Months 
After  Operation. 

6-10  Months 

After 
Operation. 

REMARKS. 

13 
14 

0.5  D  W.  R. 

7.oD.Ag.  R. 

2.5 

iowks.,3.oAg.R. 
6     "      2.0 

6 mo.,  i.sD^.R. 

iomo.,i.5Ag.R. 
10    "  1.75  W.R. 

15 

Em. 

6.0 

9     "      20       "     |4    "     12.5  Ag.  R. 

6h    "  1.25 Ag.R. 

16 

0.75  W.  R. 

4-5 

8     "      2.0       "      5    "     1.5 

7      "1-5 

17 

3-5 

8     •'      1.25     ••     16    "     E. 

18 

11. 0 

7     "      3.0       "      6    "     i.o    Ag.  R. 

19 

3.5 

9     "      2.5       " 

6    "     1.75 

20 

0.5  W.  R. 

8.0 

6     "       2.5       " 

4I  "     2.0 

21 

1.0  W.  R. 

3-5          " 

22 

Em. 

7-5 

10     "      3.0       ■' 

4i-'     3.0 

2? 

0.5  W.  R. 

7-5 

6     '•       2.0       ••      4    "     0.75 

24 

7-5 

8      "      3.0       "     ,4    "     1.75 

25 

0.75  W.  R 

I5-0 

6     "      3.5       "     \4    "     2.0 

26 

0.75  W.  R. 

3-75        " 

6      "       2.0 

27 

8.5 

7      '■       1.0       " 

4    ••     0.5  W.  R. 

28 

5-0 

8      "      2.0       '■ 

29 

5-5 

6     "       2.5       " 

5     •     2.25  Ag.R. 

30 

1-75 

10      "     1.75  W.R. 

31 

0.5  Ag.  R. 

6.5          •■ 

6      "       2.oAg.R. 

32 

9.0 

9     "      2.25     " 
8     •'      1.25     " 

33 

l.o  W.  R. 

7.0 

34 

4.5  W.  R. 

8.0 

5      ••      6.0       " 

35 

lo.o          " 

6     ■•      2.25     " 

36 

lO.O              " 

9     "      2.25     " 

37 

1-75 

10      ••       1.75W.R. 

. 

38 

Em. 

13.0 

6      -      7.oAg.R. 

39 

6.0 

8      "      2.5       " 

40 

0.75  Ag.  R. 

2-5 

8      "       1.25     " 

41 

42-59 

Em. 

.M    '■■ 

6     "      2.0 

Bciiresenta  17   c«8e«, 
which  were  only  ex- 

itmiDed  once. 

29975 

i 

Average,  6.40  D. 

Total  number  of  ca.ses,  59.    Total  astygmatism,  455.25  D.    Averagt-  of  astygmatism,  7.7  D. 

From  these  he  draws  the  following  conclusions: 

"Briefly  recapitulating,  we  see:  (1)  That  two  weeks  after  the  flap  ex- 
traction of  cataract,  there  is  corneal  astygmatism,  varying  from  1.75  D 
with  rule,  to  20.0  D,  against  rule.  (2)  That  the  greatest  amount  of  tliis 
astygmatism  disappears  in  the  following  four  to  six  weeks.  (3)  That  it  is 
ahsolutely  reduced  in  six  months,  aftci-  wliieh  it  seems  there  are  no  further 
changes." 

"Bearing  these  facts  in  mind  it  is  evident  that  an  accurate  estimation 
of  the  ultimate  glasses  can  not  he  made  at  the  end  of  two  weeks.  The  rule 
among  opthalmologists  is  to  give  a  temporary  glass  for  three  to  four  months, 
and  allow  cicatrical  contraction  to  take  place  hefore  deciding  on  the  final 
glass.  But  even  in  selecting  this  temporary  gla.<s,  heing  governed  hy  our 
table,  we  may  select  it  so  as  to  do  for  permanent  use.  In  cases  with  less 
than  5.0  I)  of  astygmatism,  which  in  four  months  is  generally  reduced  to 
1  or  2.0  I),  we  have  usually  prescribed  the  spherical  lens  which  gave  the 
best  vision,  even  though  tlie  addition  of  a  cylinder  lens  was  of  benefit  at 
the  time.  In  cases  with  more  than  5.0  D,  and  especially  in  those  in  which 
the  wound  had  healed  with  complications,  we  added  2.0  D  cylindrical,  with 
axis  indicated  hy  the  opthalmometer  and  the  test  glasses,  provided  the 


397 
vision  was  iiiii)n)V('(l.  15y  i)iittiii<i-  to-ictlicr  :i  Milliciciilly  lar^c  uumbi'i-  of 
cases,  at  least  witli  those  in  eoinplieatcd  lu'iiliiij-,  wo  may  be  able  to  arrive 
at  a  conclusion  as  to  tho  changes  to  be  expected  in  each  individual  case. 
The  subject  would.  1  think,  furnish  a  field  for  further  investigation." 

THE  APPAKENT  AND  KEAL  ACUITY  OF  VISION  IN 
APHAKIA.  Vision  in  the  aphakic  eye  is  seldom  brought  up  to  20-20, 
either  by  nse  of  spherical  glasses  or  when  they  ;ire  (•..mhiiicd  with  cylinders; 
and  this  certainly  must  become  a  very  striking  fact,  if  we  stop  to  think, 
that  the  retinal  images  in  the  aphakic  eye  are.  in  all  those  conditions  in 
which  they  are  sharply  defined,  larger  than  in  the  emmetropic  eye. 

"By  larger  I  mean  the  condition  of  the  retinal  image  as  compared  in 
the  two  eyes.  In  a  case  of  hypermetropia.  one  compares  the  image  pro- 
duced in  the  corrected  eye,  both  with  the  image  in  the  s^ime  eye  during 
accommodation,  as  also  with  the  image  which  would  appear  in  an  emme- 
tropic eye.  But  since  there  isiuj- ^psommodation  in  the  aphakic  eye,  hence 
the  first  mentioned  image  used  for  comparison  can  never  be  a  sharply  de- 
fined one.  It  certainly  is  less  a  matter  of  interest  in  any  special  case  how- 
large  the  image  will  be,  or  how  large  it  would  l)e  in  the  emmetroi)ic  eye, 
than  what  is  the  average  size  of  the  image.  Hence,  for  comparison  we 
will  again  use  the  average  eye  which  we  used  in  constructing  our  emme- 
tropic eye.  Since  the  posterior  nodal  point  almost  exactly  coincides  with 
the  nodal  point  of  the  emmetropic,  aphakic  eye,  hence  we  can  use  the  same 
figures  in  tables  XI,  XII  and  XITI,  showing  the  enlargement  and  diminu- 
tion for  both  cases." 

"This  enlargement  is  due  to  the  fact,  that  the  second  nodal  point  of 
the  combined  system  under  all  circii instances  (see  :Mauthner.  A'orlesungen 
nber  die  Optischen  F'-hler  des  Auges.  ]>.  192  and  193),  moves  in  front  of 
the  nodal  point  of  the  aphalir,  and  tlierefore,  also  in  front  of  the  second 
nodal  point  of  the  emmetropic  eye.  Hence,  the  retinal  images  of  objects 
observed  at  equal  distance,  are  to  each  other,  as  the  distance  of  the  second 
nodal  point  of  both  systems  from  the  plane  of  tlio  image,  wliich.  when  seen 
distinctly,  exactly  coincides  with  the  retina.  Hence  we  may  place  them 
in  relation  with  the  distance,  instead  of  the  si/.e  of  the  image.  (See  Manth- 
ner,  1.  c,  p.  175.)" 

"Above  it  was  stated,  that  in  a  case  of  hyperopic  aphakia,  it  would 
be  impossible  to  obtain  a  sharply-defined  image  without  a  correction.  There 
is  a  single  exception  when  the  retina  lies  in  the  .second  princii)al  focal 
plane  of  the  aphakic  system.  If  an  aphakic  eye  is  30.61  mm.  long,  then 
parallel  rays  of  light  will  come  to  a  point  exactly  on  the  retina;  that  is, 
will  form  sharply-defined  images  of  objects  placed  at  infinity.  This  image 
will  be,  as  compared  with  an  emmetropic  eye  .very  much  enlarged.    If  we  will 


398 

now  designate  the  size  of  the  image  of  an  accurately  seeing  aphakic  eye  by 
Bj,  that  of  the  emmetropic  eye  as  B,  further  the  distance  of  the  nodai 
point  from  the  retina  in  the  former  by  K2n'  ^in^^  of  ^^^^  latter  by  Kn,  hence 
the  relation  will  be  Bj :    B^K^,,:   K„.      If  we  will  now  substitute  for  the 
second  side  of  the  equation  their  values,  it  will  be 
B2 :  B=30.61— 7.7:23.86— 7,7. 
=22.91:16  16. 
=1.417:1. 
and  it  will  then  be  1:1,  417=0,  705:1;  hence,  B2=1.417B,  and  the  amount 
of  vision  thus  obtained  by  the  optometric  measurement   of  the  aphakic 
eye  is  to  be  multiphed  by  0.70."),  so  as  to  be  comparable  with  the  emme- 
tropic eye.'" 

Thus,  if  we  found  that  vision  in  an  aphakic  eye  30.61  mm.  long  was 
equal  to  f^  we  would  have  to  multiply  this  result  by  0.70,5  in  order  to 
obtain  the  actual  degree  of  vision,  as  compared  with  retinal  image  of  equal 
size,  or  expressed  differently  V=f|-  would  be  the  apparent  degree  of  vision, 
and  Y=^^xQ.705=Y=^4^ ,  or  V=-^ would  be  the  actual  acuity  of 
vision  in  an  aphakic  eye  30.61  mm.  long,  without  any  correction  for  the 
distance.  If  we  will  now  plaiie  before  the  aphakic  eye  a  convex  lens  of 
yV  at  a  distance  of  0.5"  from  the  cornea,  and  make  the  calculations  for 
this  combined  system,  we  will  find  that  K2n=29.58  mm.  Comparing  this 
with  the  emmetropic  eye,  we  will  find  that  the  increase  =  29.58:16.16  = 
1.830;  whereas  the  diminution  equals  0.546.  From  this  it  follows  that  this 
ejilargement  is  must  greater,  when,  as  in  the  case  where  a  convex  glass  of  yV 
is  placed  before  the  eye,  "the  eye  is  accommodated  for  a  distance  equal 
to  10.5." 

The  apparent  acuity  of  vision  is  determined  by  the  following: 

Vl^XJf?-!^     1-290=^, 
and  this  in  its  turn  again,  multiplied  by  the  amount  of  diminution  0.546, 
give  us  the  actual  degree  of  acuity  of  vision." 

"=15:50"  ><  ^-  ^^^=^iiM ' 

•'In  this  single  instance,  in  wliich.  aii  aphakic  eye  is  enabled  to  see 
images  perfectly  distinctly,  we  can  compare  the  acuity  of  vision  of  the 
aphakic  eye  for  near  and  far.  The  figure  re|)resenting  the  enlargefiient  of 
the  image,  v/here  we  artificially  ])roduce  accommodation  for  10.5"  distance 
equals  29.58:22.91=1.290.  By  this  means,  just  as  for  near 
V=|^Xl.290=-j|^. 

"Tlie  enlargement  or  tlie  apparent  acuity  of  vision  is  dei)end- 
ent  wliere  the  focal  sti'eiigth  of  the  convex  lens  n^ninins  the  same, 
on    its    (hslanec    from    the    eve,    and    where    llie    distance    fr(»ni    the    eyo 


399 

remains  the  same,  on  the  focal  strength  of  the  glass  chosen.  If  one  will 
at  the  same  time  so  change  both  factors,  so  that  the  focal  strength  of  the 
glass,  less  the  distance  (f-x)  always  remains  the  same,  there  will  likewise 
take  place  a  very  considerable  movement  anterior  to  the  second  nodal  point. 
All  three  metliods  ajv  iiuporljinl  in  general  practice.  T^y  means  of  the 
last  mentione<l  inelhod  one  can  very  materially,  one  might  almost  say  at. 
one's  pleasure,  increase  the  size  of  the  retinal  image  for  a  specified  dis(tance, 
and  at  the  same  time  the  apparent  acuity  of  vision  will  be  greatly  increased. 
The  first  two  methods,  as  we  shall  see,  serve  to  take  the  place  of  the  lost 
accommodation,  and  hence  we  must  try  to  compare  these  methods  with  that 
which  gives  an  apparent  enlargement,  to  see  which  gives  the  greatest  ad- 
vantages. Tables  XI  to  XIII  are  designed  to  give  a  general  idea  of  these 
conditions.  Each  one  shows  six  or  seven  complete  calculations  of  the  com- 
bined systems.  In  all  three  I  (Becker)  started  with  the  above  totally  emme- 
tropic aphakic  eye,  which  resulted  from  tlie  removal  of  the  lens  from  an 
emmetropic  eye.  Its  values  are  therefore  found  in  the  first  column  of 
each  table." 

•'In  table  XI.  using  tlie  same  eye,  instead  of  beginning  with  +  3-  ,  tins 
is  combined  with-1-^.^,  4,  |  and  at  the  respective  distances  1",  1.5",  2",  3", 4"^ 
from  the  eye.  The  individual  columns  contain  the  value?;  of  the  separately 
calculatcnl  combined  systems." 

-I^rom  the  first  column  we  at  once  learn  the  very  important  condition 
of  this  combined  system;  namely,  that  the  second  principal  point  and  the 
second  nodal  point  move  anterior  to  their  respective  first  points:  so  that 
the  value  of  Hj  Ho  Ki  K^  becomes  negative.  Wliereas  there  is  a  rapid 
increase  for  the  values  of  the  anterior  and  posterior  foeal  points,  and  also 
for  the  distance  of  the  principal  and  nodal  points  ironi  each  other,  the 
position  of  F2 ;  that  is.  the  position  of  tlie  posterior  focal  point,  remains 
unchanged. 

TABLE   XI. 
The  Emmetropic  Aphakic  Eye. 


The  correction  for  distance 

1 
35 

1 

4 

1 
4.5 

1 
5 

1 
6 

7 

The  distance  from  centre  of  cornea 

0."5 

l."0 

l."5 

2."0 

3."0 

4."0 

Anterior  focal  point  F  of  the  com- 
bined system 

20.84 

23.82 

26.80 

29.88 

85.74 

4t).78 

Posterior  focal  point  F^       .     . 

27.84 

81.88 

35.81 

89.79 

47.75 

56.71 

Distance  from  F2      .... 

28.867 

" 

" 

" 

Distance  from  H  j       .... 

-1.22 

1 .09 

6.90 

16.25 

55.10 

88.82 

Distance  from  H^     .     .     .     . 

-8.97 

-7.94 

-11.91 

-15.91 

-28.  H7 

-31.88 

H,H2=KiK, 

-2.75 

-9.08 

-18.81 

-82.16 

-78.97 

-120.65 

Distance  for  Kj 

5.78 

9.07 

15.91 

26.15 

67.11 

103.80 

Distance  for  Kj 

3.08 

0.04 

-2.90 

-6.01 

-11.86 

-16.86 

K,n 

20,88 

28.86 

26  80 

29.88 

35  74 

40.78 

Kn 

1H.16 
1.289 

1  482 

1.658 

1.849 

2.212 

" 

Enlargement  Kan:  Kn=' 

2.520 

Diminution  figure  Kn:  Kn-    , 

0.775 

0.698 

0.603 

0.540 

0.453 

0.396 

400 

"That  is  to  >;tiy.  in  all  six  cohiiuiis  the  calculations  are  made  with  the 
glass  placed  at  the  distance  from  the  eye  as  designated  above.  By  com- 
paring the  figures  which  represent  the  degree  of  enlargement  we  learn 
that  the  selection  of  a  weaker  glass  is  followed  by  an  enormous  enlarge- 
ment of  the  retinal  image.  If  we  select  a  glass  with  a  focal  length  of  1" 
instead  of  2.5.  this  enlargement  is  doubled.  And  if  we  used  a  -l-y*^^  the 
patient  would  see  the  object  seven  times  enlarged.  Vision  is  about  the 
same  as  though  one  placed  before  an  emmetropic  eye  a  — |.  and  then  in 
front  of  this,  at  a  distance  of  11"  from  the  eye,  place  a  convex  glass  with 
a  focal  distance  of  14".  This  combination  being  about  the  same  as  that 
of  a  Holland  or  Galileo's  telescope.  The  aphakic  eye,  like  every  liighly 
hypermetropic  ej-e.can  be  made  to  simulate  the  action  of  the  telescope  by  the 
use  of  a  simple  convex  lens  of  from  lO--^'"  focal  distance,  under  which  cir- 
cumstances the  hypermetropic  eye  takes  tlu^  |)lace  of  the  ocular.  An  aphakic 
eye  can  be  corrected  for  distance  by  any  convex  glass,  whose  focal  length  is 
greater  than  the  correcting  glass  i)laced  at  the  shortest  possible  distance 
from  the  eye.  During  this  procedure,  the  enlargement  of  the  image  grows 
rapidh'.  However,  as  the  distance  of  the  glass  from  the  eye  increases,  the 
field  of  vision  contracts,  so  that  after  all.  such  a  com])ination.  just  as  is 
the  case  with  the  opera  glass,  is  only  used  occasionally." 

ARTTFICTAL  A('("()M^[()I)AT1()X  IX  TJIK  APHAKIC  KVK. 

"Strictly  speaking,  an  aphakic  eye  ought  to  have  a  separate  pair  of 
cataract  glasses  for  every  distance  at  which  one  is  desirous  of  obtaining  a 
sharp  and  distinct  image.  If  one  starts  out  with  the  assumption  that  the 
distance  of  the  glass  from  the  eye  remains  unchanged  the  above  statement 
becomes  a  fact.  But  the  same  effect  can  be  produced  by  changing  the 
distance  of  the  glass  from  the  eye.  So  that,  beginning  with  a  certain  gla^s, 
which  gives  the  proper  correction  for  distance,  every  aphakic  eye  in  a  two- 
fold manner  may  be  made  to  see  objects  placed  at  a  shorter  distance.  Both 
methods  coincide,  in  that  the  position  of  the  posterior  iirineipal  focal  point 
becomes  gradually  farther  removed  t'l'oni  the  retina  of  the  aphakic  eye; 
that  is,  removed  more  anteriorly.  The  relation  of  the  i-etina  of  the  aphakic 
eye,  is  to  the  principal  focal  ])oint  in  the  lu'w  system,  as  the  retina  in  the 
mvopic  eve.  or  as  the  jti-incipal  focal  point  in  the  aci-ommodating  eye.  is  to 
the  retina  of  the  emmetropic  eye:  hence,  the  conjugate  anterior  focal  dis- 
tance lies  at  a  definite  distance  in  fi'ont  of  this  system,  lleni'i'.  the 
conjugate  anterior  focal  distance  lies  at  a  definite  distance  in  front  of  this 
system.  As  the  second  nodal  point  of  this  comhimnl  system,  also  simul- 
taneously becomes  farther  removed  from  the  retina  in  the  aphakic  eye; 
hence  under  both  conditions  the  si/A'  of  the  images  will  grow." 


40I 
"But  these  two  nietliods  of  afconiinodation  do  not  give  similar  values. 
By  increasing  the  distance  of  the  glass,  as  has  already  been  indicated,  the 
enlargement  of  the  image  rapidly  increases;  but  since  at  best  this  removal 
of  the  cataract  glasses  from  the  eye  can  not  be  farther  than  the  length  of  the 
nose  will  permit,  hence  the  usual  reading  distance  can  not  be  arrived  at 
by  this  means.  True,  by  choosing  a  stronger  glass,  ])laced  at  the  ordinary 
distance  from  the  eye,  this  enlargement  takes  place  less  rapidly  than  in 
the  former  case;  however,  there  is  no  reason  why  a  glass  should  not  be 
chosen,  by  means  of  which  objects  can  be  sharply  discerned  at  a  distance 
of  8-10",  or  a  little  farther.  For  this  reason  this  latter  method  finds  more 
general  approval.  Tables  Xll  and  XIII  explain  this  under  all  possible 
conditions.  Both  tables  start  out  with  the  emmetropic  average  eye  which 
has  become  ajihakic." 

TABLE   XII. 
The  Emmetropic  Aphakic  Eye,  combined  with  -|-  -^  with  distance  from  the 
centre  of  Cornea. 


= 

0."6 

0."75 

l."00 

l."26 

I."5 

l."76 

2."00 

Anterior  focal  dis- 

tance F .        ... 

20.84 

22.29 

23.96 

25.89 

29.08 

30.88 

34.18 

Posterior  focal  dis- 

tance Fj        ... 

'27M 

29.78 

32.91 

34.60 

37.64 

41.26 

45.69 

Distance  from  F^ 

2i-i.m 

23.40 

22:87 

22.25 

21.61 

20.63 

19.60 

Distance  from  Hj   . 

-1.22 

-0.56 

-1.24 

3.22 

9.34 

16.50 

26.64 

Distance  from  H'^ 

-8  97 

-6.38 

-9.14 

-12.35 

-16.13 

-20.63 

-26.09 

H,H2=K.K,     .     . 
Position  from  K, 

-2.75 

-5.82 

-10.38 

-15.57 

-26.47 

-37.13 

-52.73 

3.78 

6.93 

9.29 

11.90 

20.25 

30.11 

42.41 

Position  from  K^    . 
K.n 

8,03 

1.11 

-1.09 

-3.67 

-6.22 

-7.02 

-10.32 

20.84 

22.75 

24.95 

27.63 

29.08 

30.88 

34.18 

Kn 

1(5.16 

" 

" 

" 

" 

" 

" 

K,n:Kn=i      .     .     . 

1.289 

1.407 

1.643 

1.703 

1.799 

1.910 

2.115 

Kn:Kjn=,    .     .     . 

0.775 

0.710 

0  648 

0.587 

0.556 

0.524 

0.472 

T-v  ,    (  Mm  .... 

}' 

1465.88 

789.68 

679.05 

4.6677 

400.90 

374.12 

^»      (  P.  Z.     .     .     . 

54.1 

29.1 

21.3 

17.8 

14.8 

13.0 

NOTE.— lu  this  and  the  followiug  table  F^  equals  the  anterior  focal  distance 
of  the  aphakic  eye  in  its  proper  relation  to  the  retina,  or  is  equal  to  distance  for 
which  the  eye  is  accommodated,  liy  placinji  before  it  a  convex  j-lass,  calculated 
just  as  R  in  table  X. 


TABI,E   XIII. 

The  Emmetropic  Aphakic  Eye,  with  the  glass  at  0.5"  distant  from  the  Cornea 


Combined  with  + 


Anterior  focal  distance  Fj  . 
Posterior  focal  distance  F^ 
Position  from  F^    .     .     .     . 
Distance  from  Hj     .     .     . 
Distance  from  H^  .     .     .     . 

HiHjKiK^     

Distance  from  Kj  .     .     .     , 
Distance  from  K,     .     .     . 

K^n 

Kn 

K2n:Kn=i        

Kn:K,n=. 


F,  in 


Mm 
P.  Z. 


3.5 

3 

2.75 

1 

2.25 

2 

20.84 

20.54 

20.34 

20.12 

19.96 

19.*>3 

27.84 

27.44 

27.18 

26.86 

26.63 

26.L9 

23.86 

22.82 

22.24 

21.49 

20.64 

19  56 

-1.22 

-1.41 

-1.62 

-1.66 

-1.81 

-.■.00 

-3.97 

-4.58 

-4.94 

-5.37 

-6.89 

-(:.64 

-2.75 

-3.17 

-3.42 

-3.72 

-4.08 

-4.54 

6.78 

5.45 

5.32 

6.09 

4.87 

4.56 

3.03 

2.28 

1.90 

1.37 

0.79 

0.02 

20  84 

21.59 

21.97 

22.50 

23.08 

23.85 

16.1H 

" 

" 

" 

" 

" 

1.298 

1.347 

1.363 

1.392 

1.422 

1.475 

0.775 

0.742 

0.739 

0.711 

0.703 

0.677 

}» 

562.91 

369.29 

249  79 

184.64 

139.75 

20.7 

13.6 

9.2 

68 

5.1 

In  table  XII  the  glass  of  -^  has  been  removed  from  the  eye  from  ^  to 
4"  up  to  2  '.  But  even  by  bringing  about  the  furtherest  possible  distance 
from  the  eye,  the  artificially  produced  near  point  could  only  be  brought 
up  to  13"  from  the  eye.  JSTevertheless,  the  enlargement  grows  until  it  has 
doubled  itself.  In  table  XIII  the  various  glasses,^, -^,-^j-^,^aTe  all 
placed  at  an  equal  distance.  On  using  -^  the  aphakic  near  point  reaches 
9"  distant  from  the  eye.  With  |  the  eye  can  see  distinctly  at  5".  Whereas, 
by  such  an  excessive  {Accommodation,  the  enlargement  only  becomes  one 
and  one-half  times  enlarged. 

THE  SELECTIOX  OF  SPHEEICAL  GLASSES.  "In  practice,  as 
a  rule,  we  begin  to  seek  the  proper  correction  for  distance  by  use  of  a  +\ 
(4-10  I)),  and  where  we  do  not  get  the  requisite  amount  of  vision  we  move 
the  glass  either  a  little  nearer  or  a  little  further  away  from  the  eye.  If  in 
the  latter  position  sight  is  improved,  we  take  a  stronger  glass  and  continue 
this  procedure.  In  this  manner  we  soon  arrive  at  the  glass  which  gives 
the  best  result.  In  the  other  case  we  go  f roni  ^,  i,  |-,  etc.  After  having  in 
this  manner  arrived  at  the  proper  glass  for  distance,  we  can  in  like  manner 
arrive  at  tha  proper  correction  for  reading.  However,  one  will  save  time 
if  one  will  bear  in  mind,  that  to  the  glass  which  gives  a  proper  correction 
for  an  infinte  distance,  sliould  l)e  added  the  glass  having  the  reciprocal 
value  for  a  distance;  thus,  if  the  correction  for  infinity  is  -^  to  accommo- 
date for  a  distance  of  20",  we  would  have  -^-j-~=^  (exactly  -^V)'  ^^^ 
10.5"  would  be  -^-^^Xj^=z-^  (exactly  ^V)'  ^^^-  Naturally,  one  does  not 
have  all  the  lenses  corresponding  to  these  fractional  figures  the  result  of 
calculation,  so  one  uses  the  lens  which  comes  nearest  to  it  in  the  test  case, 
and  we  correct  the  slight  difference  bv  the  distance  at  which  the  glass  is 


403 

placed   fi'oni    the   vyv.      Any   one    who   iiiiir^t    frequently   prescribe   strong 
glasses  for  distance,  soon  learns  to  give  the  proper  correction  for  near." 

''The  dioptric  system  now  being  in  use,  having  once  found  the  cor- 
rection for  distance,  the  glass  for  near  is  very  easily  found  by  adding  to 
this  the  glass  which  would  re])resent  the  amplitude  of  accommodation  up 
to  the  j)oint  at  which  the  patient  wishes  to  read.  ''JMuis.  if  this  be  25  cm. 
j%V  -iJ)-  tlien  if  glass  re(|uired  for  distance  is  KH)  for  near,  10 -j- 4  D 
=  14D  would  1)1'  rc((uiir(l:  if  this  is  1  "i  1 )  for  near,  l".^  -  -  1  D-inD  would 
be  required." 

In  order  to  see  a  point  distinctly,  wliidi  is  at  a  distance  Y  removed  from  the 
lens,  the  rays  of  light  wliicli  emanate  from  it.  after  they  have  passed  through 
a  lens  having  a  focal  lengtii  of  F^,  which  is  accommodated  for  near,  must  con- 
verge tf»  the  same  point,  as  do  parellel  rays  after  they  h»«e  been  deflected  by 
a  lens  F,,  which  is  tlie  proper  corrpctton  for  distance.  This  mutual  dependence 
of  Y  and  F'2  is  expressed  <by  the  conjugate  focal  distancei  in   tlie  following 

equation:  JL-|-A=J' 
y      !•'.     »••. 

"By  calculating  the   value  of  y   we  get   the   |)oinl   at    which  distinct 

vision  is  possible  in  front  of  the  lens.     To  get  the  exact  distance  at  which 

distinct  vision  is  to  be  obtained  in  front  of  the  cornea  or  the  nodal  point  of 

the  eye.  this  distance  from  the  lens  from  these  points  is  to  be  added.'' 

Having  foimd  the  correcting  glass  for  distance,  it  becomes  a  matter  of  in- 
terest to  know  with  exactly  which  glass  placed  at  the  same  distance,  it  would 
become  possible  to  see  distinctly  at  Kf  or  S"  from  the  eye.     Thus,  if  F'  ^  \  and 

y=10,"  then  i_=J— |-J-=1M=_L.    Now,  if  we  retain  the  value  of  F'  ,  and  if  y     S", 
Fa        10   '  3.5       35      2  oH  ^  J  > 

then  -L  =_L4-J.=li^__L. 
F^        1«    '  3.5       28       •i.43 

Hence,  one  would  see  distinctlv  at  a  distance  of  10,  5"  Avith  a  lens    JL   at 

2.59 

a  distance  of  ().."►"    from  the  eye.  and  distinct  vision  at  S.r>"    with  a  lens      l 

2  43, 

0.5^' from  the  eye.     Since  both  of  tliese  glasses  are  not  found  in  the  test  case, 
one  chooses  the  nearest  glass,  J-,  and  if  the  distance  of  the  glass  before  the 
eye  is  not  changed,  accurate  vision   will  l)e  attained,  at  S."/'  from  the  glass, 
9.25'''  from  the  cornea  and  at  •.t.tio"  from  the  nodal  point  of  the  eye. 

"N'ow.  if  one  will  look  iti  table  XI 11  and  tiiul  the  distance  for  which 
an  aphakic  eye  is  focus  when  armed  with  a  convex  glass  of  ^  focal  dis- 
tance, placed  at  o.")''  distance,  one  will  find  that  this  is  given  in  the  fifth 
column  as  ^^  which  coincides  with  our  M'cond  value.  9.25.  At  the  same 
time  we  discover  that  the  degree  of  vision  for  near  objects  is  much  greater 
than  for  distance  would  have  led  us  to  e.\|)ect.  The  reason  for  this  is,  as 
has  already  been  indicated,  due  to  the  inc •rea>e  in  size,  owing  to  the  strength 
of  the  convex  glass  used." 


404 

If  the  degree  of  vision  attained  is  not  sufficient  to  answer  the  require- 
ments of  the  patient,  we  have  another  means  at  our  disposal  to  enlarge 
the  retinal  images,  and  thus  to  increase  the  apparent  degree  of  vision,  one 
eitlier  removes  tlie  glass  furtlier  from  the  eye  or  one  uses  a  stronger  glass. 
But  in  hoth  cases,  as  can  be  seen  from  tables  XII  and  XIII,  the  object  must 
be  brought  nearer  to  the  eye.  The  patient  then  sees,  if  one  may  use  the 
expression,  as  if  he  were  looking  through  a  Galileo's  telescope,  or  is  using 
a  lens  to  enlarge  images. 

From  all  that  has  been  said  it  will  be  seen,  that  no  statistical  results 
are  of  any  value,  in  which  simply  the  number  of  the  Snellen  or  Yager's 
test  t}'pe  read  are  given,  only  then  do  they  give  a  correct  idea  as  to  the 
degree  of  vision  attained,  when,  at  the  same  time,  the  distance  at  which 
they  are  read  is  also  stated.  But  even  then  the  most  tiresome  calculations 
are  necessary,  since  the  smallest  test  type  of  Yager  and  Snellen,  in  cases 
of  normal  vision,  must  be  read  at  a  much  greater  distance  than  is  the  usual 
reading  distance." 

THE  CYLIXDEICAL  CORRECTION.  "Just  as  soon  as  one  finds 
that  the  amount  of  vision  attained  for  either  distance  or  near  does  not 
equal  the  a^^rage  degree  which  ought  to  be  attained  by  the  use  of  spher- 
ical glasses,  the  attempt  fih-euld  be  made  to  improve  this  by  the  use  of 
cylinders.  Reuss  and  Woinow  have  demonstrated  to  us,  that  in  most  cases 
this  procedure  will  be  successful,  if  there  is  not  a  very  large  secondary 
cataract  present.  If  we  have  found  the  cylindrical  correction  for  distance, 
we  simply  add  this  to  the  spherical  combination  for  near." 

"The  above  named  authorities  claim  to  have  found,  that  in  the  aphakic 
eye,  at  times  when  looking  at  near  objects,  the  degree  and  position  of  the 
meridian  in  which  the  astygmatism  lies  is  changed;  however,  this  observa- 
tion has  never  been  corroberated  by  any  other  observers." 

"As  a  rule,  the  number  of  the  cylindrical  glass  is  found  by  experiment, 
but  in  order  to  save  time  one  may  start  out  with  the  average  degree  (iV  fo 
yV).  and  place  it  in  the  well-known  direction  of  least  curvature  which 
appears  after  cataract  operations.  A  very  valuable  control  experiment  is 
that  of  measuring  the  corneal  curvature  with  the  opthalmometre.  Since 
when  we  have  arrived  at  the  corneal  astygmatism,  we  have  at  the  same 
time  arrived  at  the  total  astygmatism  of  the  entire  eye." 

"Reuss  and  Woinow  have  advised  the  use  of  a  cylinder,  as  found 
by  opthalmometric  examination;  but  still,  since  following  this  examina- 
tion,, one  must  still  test  to  see  how  much  vision  is  attained,  one  can  not 
see  why  this  procedure  is  to  be  preferred." 

"Thomas  Young  showed  that  by  placing  a  spherical  convex  lens 
obliquely,  the  homoccntric  rays  of  light  which  fall  on  it  do  not  exactly 
come  to  a  point,  but  come  together  in  two  lines  placed  vertical  to  each 


405 
other.  s(i  that  we  i.m  pnxhu-c  a  similar  cH'cct  liy  |>la(iii;^-  the  ^ilass 
sonu'what  ()l)li(|n("ly  t--  the  Wiw  of  vision,  tliii-  pi-odiiciiin-  an  •■llV'tt 
anah)^ous  to  the  combination  of  a  spherical  and  cylindrical  lens.  And  it 
is  well  known  that  those  who  wear  glasses  often  unconsciously  correct 
slight  degrees  of  astygniatisni  by  bending,  moving  forward,  or  displacing 
their  spectacle  frame." 

"We  often  find  patients  who  have  undergone  cataract  operation  place 
their  glasses  in  aJi.obli(iue  position.  Every  beginner  often  is  very  much 
confused  to  find  the  patient  state  that  at  times  he  sees  better,  at  times 
worse  with  the  same  glass,  or  is  unable  to  explain  this  condition  satisfac- 
torily to  himself;  or  in  other  words,  that  he  can  see  better  with  his  spec- 
tacles than  he  can  with  a  glass  of  the  same  focal  strength,  which  the  phy- 
sician places  in  front  of  his  eye.  Both  conditions  are  explained  by  the 
cylindrical  action  of  a  glass  held  obliquely.  That  which  the  patient  often 
does  unconsciously  is  often  a  valuable  aid  in  the  hand  of  the  physician, 
who  in  this  simi)le  manner  can  increase  the  degree  of  vision.  Donders 
drew  attention  to  the  fact  in  1864,  and  Java!  used  it  in  1865,  and  I  belieye 
that  in  many  cases  one  can  avoid  giving  a  cylindrical  correction  by  employ- 
ing this  means.  Unfortunately  as  yet  we  have  no  scientific  explanation 
for  this  practical  and  important  subject." 

THE  INFLUENCE  WHICH  GLASSES  EXEKT  ON  THE  VISION 
OF  APHAKIC  EYES. 

a.  CONTRACTION  OF  THE  FIELD  OF  VISION.  From  time 
immemorial  it  has  been  customary  to  prescribe  large  round  glasses  for 
cataract  glasses.  It  was  supposed  that  by  this  means  we  could  increase 
the  size  of  the  field  of  vision.  Many  patients,  however,  remonstrated 
against  such  glasses,  because  the  weight  often  became  a  burden,  and  fre- 
quently the  patients  would  go  and  have  them  cut  oval.  By  doing  this 
they  did  the  proper  thing  in  more  ways  than  one." 

"Already  Thomas  Young  had  shown  that  rays  of  light  passing  through 
a  bi-convex  lens  placed  obliquely,  did  not  come  together  at  a  single  point, 
but  in  two  focal  lines  at  a  certain  focal  distance.  This  departure  from  the 
regular  refraction  increases  with  the  size  of  the  exposed  surface  of  the 
glass,  and  with  the  angle  at  which  the  glass  is  placed,  and  with  its  curva- 
ture. As  a  result,  when  looking  through  convex  glasses,  objects  in  the 
periphery  of  the  field  of  vision  look  distorted.  To  overcome  this  exi\  effect 
Wollaston  constructed  his  periscopic  glasses:  whereas  several  practical 
opticians  of  his  time  advised  glasses  of  a  smaller  diameter,  since  they  started 
out  with  the  assumption,  that  the  outer  portion  of  the  retina  is  less  sensi- 
tive, hence,  could  well  get  along  without  an  optical  correction  without  any 
evil  effects.    The  advantage  which  Wollaston  hoped  to  get  from  periscopic 


4o6 

glasses  has  not  been  practically  realized,  at  least  for  convex  glasses.   Since 

it  was  shown  that  the  so-called  prismatic  displacement,  at  least  for  the 

periscopic  glasses,  is  just  as  great  as  it  is  with  bi-convex  or  plain  convex 

glasses." 

"When  weak  convex  glasses  are  ns«l,  tliis  disturbance,  so  far  as  the 
excentric  vision  is  concerned,  is  not  very  great.  But  if,  as  is  the  case  with 
those  who  liave  undergone  a  cataract  operation,  strong  convex  glasses  are 
exclusively  used,  we  find,  as  Berlin  showed,  that  it  is  not  a  matter  of  dis- 
tortion, but  a  zonular,  concentrically-defined  defect  in  the  periphery  of 
the  field  of  vision.  Even  when  the  large  round  circular  cataract  glasses 
are  used,  the  outer  periphery  of  the  retina  receives  its  light  direct,  without 
passing  through  the  cataract  glasses.  Owing  to  the  highly  prismatic  action 
of  the  edges  of  the  cataract  glasses,  light  does  not  reach  the  pupil  from  a 
not  inconsiderable  zone  of  the  field  of  vision.  And  since  a  total  reflection 
also  takes  place  from  the  edges  of  the  cataract  glasses,  Berlin  especially 
draws  attention  to  the  fact,  that  this  zone  is  not  sharply  outlined  in  any 
direction  as  a  result  of  the  action  of  this  total  reflection.  Since  the  outer 
limits  of  the  field  of  vision  are  more  dependent  on  the  size  of  the  glass, 
by  making  tlwse  smaller  we  can  at  least  limit  this  eccentric  loss  of  the 
peripheric  field  of  vision.  Hence,  I  see  no  reason  why  we  should  prescribe 
large,  heavy,  and  therefore  very  uncomfortable  cataract  glasses  instead  of 
the  oval  glasses,  when  at  the  same  time  we  desire  the  benefit  of  a  diminu- 
tion of  the  peripheric  distortion,  and  loss  of  the  excentric  portion  of  the 
field,  especially  above  and  below."" 

'Tor  the  upper  half  of  the  field,  the  advantage  certainly  would  not 
be  of  any  great  importance,  but  when  glancing  downward  the  condition 
of  affairs  certainly  assumes  great  importance.  Only  too  often  do  cataract 
patients  complain  of  defective  ability  to  exactly  locate  objects.  In  walking, 
especially  in  going  up  or  down  stairs,  they  are  frequently  inipeded,  so  that 
many,  especially  when  they  have  a  slight  myopia,  prefer  to  walk  about 
without  their  glasses.  On  using  the  oval  glasses  this  defective  power  of 
locating  objects  is  at  once  corrected.  Undoubtedly  the  patients  receive 
inaccurate  images  of  the  floor  on  which  they  are  walking,  but  at  the  same 
time  they  do  not  receive  interrupted  or  distorted  ictinal  images."" 

"Owing  to  the  highly  prismatic  deflection  which  all  the  rays  of  light 
receive,  except  those  which  traverse  the  rvuiw 
especially  careful  to  i^ec  that  in  cases  where  hot 
the  glasses  are  perfectly  ceiitei'ed.     Oiheiwise. 
asthenopic  trouble  will  arise."" 

"If  only  the  one  eye  has  been  o])i'rate(l.  an 
be  used  to  see  with,  the  glasses  foi-  distance  an 


)!'   1 

he  glas 

s.   we 

nnist  be 

e\e 

s  have 

hecn 

operated. 

■|-y 

annoying  di] 

tlopia   or 

th. 

■  other 

can  ti 

lo  longer 

ne; 

ir  may 

\)V  pi: 

it  in  one 

407 
frame,  with  a  neutral  nose  piece,  if  n  lii<ili  l)vi(l>io  on  the  no?e  doe?  not 
veto  such  a  procedure." 

"Hence,  tlie  field  of  vision  of  the  aphakic  eye  extends  over  ns  much 
space  as  does  a  complete  eye.  Only  the  former  can  not  see  so  well,  in  tlie 
periphery  as  in  the  center,  even  wlu-ii  provided  willi  j,dasses,  owing  to  the 
distortion  of  the  images.  And  this  incc.nvcnience  is  increased  hy  the  cata- 
ract glasses.  This  contraction  of  ihc  field,  as  a  result  of  the  ust>  of  the 
convex  glasses,  becomes  increased  when  the  distance  of  the  glasses  from  the 
eyes  is  increased.  Hence,  owing  to  these  conditions,  accommodation 
can  be  accomplished  by  the  use  of  stronger  glasses.  Naturally,  the 
increase  in  the  apparent  acuity  of  vision  for  distance  suffers  also  where 
there  is  a  very  large  contraction  of  the  field  of  vision.  Hence,  it  is  almost 
impossible  to  wear  continuously  in  front  of  both  eyes  glasses  far  removed, 
notwithstanding  the  pleasure  which  such  patients  may  derive  from  wearing 
their  simple  opera  glasses." 

EXACT  CENTERING.  -Jn  the  selection  of  cataract  glasses  more 
depends  on  the  selection  of  a  proper  frame  than  on  any  other  condition  in 
which  glasses  are  required,  for  on  this  is  dependent  the  fact  whether  the 
eye  and  the  glass  will  be  properly  centered.  For  instance,  the  prismatic 
deflection  when  using  a  +^  at  1  mm.  distance  from  the  center  is  as  great 
as  in  a  +1^  at  3  mm.  distance  from  the  center  (1°  15').  By  this  means  not 
only  is  there  a  very  perceptible  distortion  of  objects,  and  the  arrangement 
of  the  same,  brought  about  in  the  periphery  of  the  field  of  vision,  but 
light  is  broken  up  into  its  various  colors,  which  becomes  very  annoying 
to  the  patient.  Hence,  no  one  who  is  necessitated  to  wear  glasses,  worries 
himself  so  long  and  so  persistently,  so  as  to  get  them  in  a  proper  position 
in  front  of  his  eyes,  as  does  the  patient  operated  on  for  cataract." 

•'As  long  as  only  one  eye  has  been  operated  on,  we  may  permit  the 
patient  to  worry  himself  in  getting  his  glass  properly  centered.  But  in 
prescribing  cataract  glasses  for  both  eyes,  other  factors  come  into  play, 
such  as  the  occurrence  of  diplopia,  and  we  must  take  into  consideration 
the  muscular  condition  of  the  eyes,  and  then  it  becomes  the  physician's 
duty  to  see  that  the  glasses  have  a  proper  ]iosition,  in  their  relation  to  the 
eyes,  according  to  the  general  fundamental  rules.  If,  as  i?  usually  the 
case  under  such  circumstances,  we  prescribe  separate  glasses  for  distance 
and  near  work,  we  must  at  least  approximately  take  into  account  for  each 
special  case,  the  iingle  which  the  lines  of  vision  must  make  with  each 
other,  and  aside  from  this  we  must  see  to  it  that  the  glasses  are  so  bent 
as  to  form  an  obtuse  angle,  open  anteriorly." 


4o8 

FEW  PECULIARITIES  OF  APHAKIC  VISION.  a.  Entopic 
Vision.  It  vvould  hardly  seem  necessary  to  state,  that  in  consequence  of 
loss  of  the  lens,  all  entopic  phenomena  which  arise  in  the  lens  system  are 
wanting,  if  it  were  not,  that  at  times  during  the  formation  of  a  cataract, 
these  ])henomena  force  themselves  to  the  attention  of  the  patient  in  the 
most  disturbing  manner. 

In  aphakia  the  patient  becomes  aware  of  opacities  in  the  vitreous 
under  entirely  changed  optical  conditions.  Since  the  entire  vitreous  has 
moved  perceptibly  away  from  the  focal  ]ihine:  lience,  where  no  cataract 
glass  is  used,  every  cloudiness  in  the  same  must  cast  a  shadow  on  the  retina, 
and  since  the  power  of  accommodation  is  wanting,  hence  all  vitreous  opaci- 
ties will  at  once  be  recognized,  as  soon  as  an  eye  equipped  with  cataract 
glasses  directs  its  attention  to  any  object  which  is  at  a  distance  equal  to 
that  for  which  the  glass  is  intended. 

ERYTHEOPSIA.  A  peculiar  sul)jective  phenomenon  of  the  aphakic 
eye  is  the  sudden  occurrence  of  red  vision,  of  which  the  patients  not  infre- 
quently complain,  and  which  frightens  them  greatly  the  first  time  it  occurs. 
It  occurs  suddenly;  at  times  it  lasts  but  a  few  minutes;  in  other  cases,  hours 
and  even  days.  It  always  disappears  gradually.  Since  all  patients  who 
observe  this  are  sure  to  relate  it  to  their  physicians,  hence  it  can  be  stated 
with  certainty  that  it  occurs  in  from  3  to  5  per  cent,  of  all  cases. 

Since  no  evil  results  luive  ever  been  observed  following  its  occur- 
rence, one  is  justified  in  quieting  the  fears  of  the  patient  by  making  a 
good  prognosis.  Becker  had  the  oi)i)ortunity  repeatedly  to  examine,  wdth 
the  opthahnoscope,  such  a  patient  during  an  attack,  and  believed  that  he 
might  safely  state,  that  he  did  not  observe  a  hyperaemia,  either  of  the  retina 
or  the  optic  nerve. 

Erythropsia  has  been  the  subject  of  considerable  investigation  by 
Hirschler,  Dimmer,  Purtscher,  Meyerhauser,  Steiner,  Benson  and  many 
others. 

Dr.  Hirschler  has  been  the  subject  of  this  peculiar  phenomena  him- 
self, and  has  given  us  a  graphic  description  of  his  sensations. 

He  states  4  tiiat  he  had  always  been  very  near  sighted  (M.  1-10.  suffered  from 
mouehes  volaiites.  and  frequently  scotoma  scintillans  fu^ax).  Strong-  lijiht  al- 
ways caused  trouble,  and  frequently  caused  "nachbilder."  In  1878  his  left  eye 
became  diseased,  and  in  1880  cataract  developed  in  liis  right.  In  1882  a  Von 
Graefe  extraction  with  a  broad  coloboraa.  With  the  exception  of  micropsie.  the 
process  of  healing  and  convalescence  was  perfect.  Notwithstanding  astygma- 
tlsm  with  a  4  5i/.  V  •^1],  and  with  a   +  .">^',.  read  Y  1.       Tlie  r)eculiar  phenomena 


4Zum  Uothselien  dcr  .\piialviselicn.    Welncr  Med.  Wochcnsclu-ift,  4.  6.  1883. 


409 
of  orythropsia  bi'^iau  the  tiftli  month  after  the  oi)eration.  As  soon  as  evening 
approached  the  entire  tirniauient  appeared  red.  wliereas  all  tern'strial  oltjects 
were  red  throngh  the  reflection  of  tlie  red  light  from  above.  This  phenomenon  was 
also  present  indoors,  but  only  on  looking  toward  the  windows.  This  continued 
regularly  for  about  one  hour,  gradually  disappearing.  During  the  continuance 
of  this  phenomenon  the  acuity  of  vision  was  not  reduced.  Even  on  cloudy  days 
this  red  discoloration  of  the  tirmament  did  not  fail  to  appear,  even  if  the  rain 
was  coming  down  in  torrents.  This  phenomenon  never  oc<-urr^d  during  the  day. 
However,  if  the  eyelids  were  brought  sufficiently  close  together  this  red  discol- 
oration could  be  made  to  disappear  during  the  evening.  However,  closure  of 
the  right  cataractous  eye  did  not  exert  the  slightest  influence  on  this  phe- 
nomenon. Towards  the  fall  of  the  year  tlie  erythropsia  disappeared  just  as 
suddenly  as  it  had  come.  He  .seeks  the  cause  in  the  large  iris  colobom.  not  as 
a  result  of  the  colored  rays  of  dispersion,  but  rather  as  a  result  of  the  intensity 
of  the  light  which,  falling  on  the  peripheric  portions  of  the  retina,  caused  there 
an  unusual  degree  of  irritation.  This  excessive  irritation  is  followed  by  exhaus- 
tion. In  this  ease,  the  peripheral  portion  of  the  retina  being  so  exhausted  that 
light  at  twilight  was  not  strong  enough  to  arouse  sensation  to  its  fullest  de- 
gree. This  exhaustion  must  manifest  itself  for  rays  of  light  which  have  higher 
indices  of  refraction,  whereas  the  sensitiveness  for  the  red  rays  is  still  present, 
as  a  result  of  which  the  field  is  colored  red.  The  results  of  experiments  with 
stenopaic  glasses  verifies  this. 

Piirt8cher°  investigated  this  subject,  (Irawing  the  followiiii--  coiiehision: 

1.  That  eri/thropsia  is  not  an  optical  phcnomoion.  Dispersion  of  colors 
could  not  be  thought  of,  becaii.se  then  only  tlie  edges  of  objects  would  be 
colored. 

Two  causes  might  be  thought  of,  cloudiness  of  media  or  hemorrhages 
in  the  vitreous,  but  both  can  be  set  aside  because  if  present  they  could  be 
detected  with  the  opthalmoscope.  Further,  there  is  no  reduction  of  acuity 
of  vision  during  the  time  everything  appears  red  to  the  patient. 

2.  The  orcurrence  of  erythropsia  in  aphhia  is  not  dependent  on  the  pres- 
ence of  a  coloboma.  In  his  own  ca.se  of  traumatic  cataract,  likewise  in  Dim- 
mer's case,  there  was  no  coloboma. 

S.  An  explanation  on  the  basis  of  tonlrast  in  colors  can  nol  he  linnii/ht 
in  accordance  with  the  facts.  I'hough  it  has  been  supposed  that  after  re- 
maining for  a  long  time  where  everything  is  green,  the  complimentary 
color  red  will  appear.  One  fact  mitigates  greatly  against  this  a.^suniption, 
for  in  many  ca.ses  the  red  appeared  at  (uice  on  waking  in  the  morning. 


5Zur    Frage    Krythropsia.      Centi-.-illilntt    fur    Prakrischer    Augenheilkunde, 
.luni.  ISS;?. 


4IO 

4.  Hirschhr's  e.rplanalion  has  a  pln/sioJoyicnl  basis  for  it.  He  explains 
ilie  eryihropsia  as  dve  to  fatigue  of  the  retina,  tvhich  becomes  most  evident  in 
the  evenin(/.  and  manifests  itself  mostlij  for  the  more  hiqhlii  reflective  rays, 
whereas,  the  rays  of  less  refractive  power  can  still  art. 

Aubert  ^  states  that  sensitiveness  for  blue  or  green  is  lost  in  ten  min- 
utes, when  dark  blue  or  dark  green  glasses  are  worn;  whereas,  red  can  still 
be  seen  after  several  hours.  One  might  suppose  that  a  retina  which  be- 
comes fatigued  'very  rapidly  (for  colors),  would  lose  its  sensitiveness  for 
refractive  rays  of  diffuse  light  much  sooner  than  its  sensitiveness  for  the 
less  highly  refractive  red  rays. 

Further,  one  ought  not  forget  the  fact  that  among  pigments  red  can 
still  be  recognized  where  the  intensity  of  the  light  is  reduced,  after  all  other 
colors  can  no  longer  be  seen.  Hence,  it  would  seem  that  the  Conditions 
for  the  recognition  of  red  rays  are  more  favorable  when  the  iMensity  of 
the  illumination  is  reduced. 

This  fact  becomes  still  more  important  where,  in  a  fatigued  eye, 
hemeralopia  also  is  present  (as  Hirschler  states  of  his  own  case),  and  which 
he  assumes  to  occur  generally  in  aphakics,  where  coloboma  has  been  made. 

5.  This  phenomenon  of  seeing  everything  red  is  purely  a  subjective  one, 
and  has  its- seat  in  the  sensitive  apparatus  ivhich  receives  the  rays  of  light. 
It  is  partly  direct,  partly  indirect,  depending  on  nervous  influences. 

For  the  former,  one  can  assume,  that  a  retina  which  had  been  shielded 
for  a  long  time  from  the  more  intense  impression  of  light  by  a  developing 
cataract,  would  certainly  be  more  sensitive  to  the  action  of  light  after  the 
obstacle  had  been  suddenly  removed.  Likewise,  the  tendency  to  fatigue 
would  be  greater. 

He  gives  a  series  of  cases  and  further  investigations,"  and  after  review- 
ing all  the  literature,  reasserts  all  the  above,  and  finally  concludes: 

"This  ]jhenomenon  of  seeing  red  is  purely  a  subjective  one.  due  to 
irritation,  or  finally,  a  fatigue  of  the  visual  apparatus — the  result  of  partly 
direct,  partly  indirect,  nervous,  special  and  vaso-motor  influence.  Indi- 
viduals of  a  naturally  nervous  disposition  and  aphakic — possibly  more  cor- 
rectly, those  who  have  suffered  from  cataract — are  predisposed.  This  pre- 
disposition is,  in  all  probability,  heightened  by  coloboma." 

Immediately  after  delivery  of  the  lens,  patients  not  infi-equently  see 
everything  in  a  color  other  than  normal,  as  jier  e.\am])le.  the  finger  looks 


6Graefe  Saenisch  H..  II.  2.  S.  "mT. 

7  Foer.ster  Koitrajio  zur   Fni^o  dcr   Kiytluojtsic.    o.    I'urtsclun-  Contralblatt 
fur  AuK«'nlicilknii(l.'.  FchniMrv  .mikI  .March.  1SS4. 


411 

blue.  One  lookod  upon  I  his  ns  a  coiit  ra-1  action:  for  as  we  stalled,  an  inu-nso 
yellow  color  of  the  nucleus  influenced  llie  jxTception  of  colors  in  the  cata- 
ract patient.  Fnder  such  circumstances  we  would  expect  this  phenomenon 
to  disappear  a  certain  length  of  time  after  delivery  of  the  lens,  and  ought 
to  be  entirely  wanting  in  soft  cataracts,  which  have  a  yellow  nucleus.  Roth, 
however,  are  not  true:  it  can.  however,  be  shown  ihat  this  phenomenon 
is  due  to  particles  of  lens  substance  left  behind  in  the  aqueous,  and  to 
very  finely  diffused  blood.  This  blue  discoloration  always  disappears  as  so(ui 
as  the  lens  substance  is  absorbed.  At  times  simi)ly  permitting  the  aqueous 
to  be  evacuated  a  number  of  times  by  separating  the  edges  of  the  wound, 
is  sufficient  to  cause  the  finger  held  before  the  eye  to  again  assume  its 
normal  color. 

Fuchs*^  has  given  us  the  most  exhaustive  exposition  on  this  s\ibject, 
and  has  shown  that  erythropsia  may  occur  in  normal  eyes,  lie  came  to  the 
conclusion  that  the  cause  must  be  sought  in  some  dii-ection  other  tiuin  in 
the  illuminated  field.  He  found  that  erythropsia  ensued  even  when  colored 
glasses  were  used,  and  concluded  that  the  erythropsia  is  entirely  independ- 
ent of  the  color  of  the  light.  Finally,  he  sought  its  origin  in  the  color  of 
the  visual  purj^le  of  ihe  retina,  which  begins  to  regenerate  every  time  the 
eye  is  removed  from  the  influence  of  the  light.  He,  however,  indicates 
that  he  can  not  explain  why  at  times  the  red  seeing  is  preceded  by  green. 
Snellen  ^  believes  that  this  is  a  contrast  phenomenon.  The  portion 
of  the  eye  which  had  been  exposed  to  the  bright  light  will  appear  red, 
whereas  the  portion  which  has  been  protected  (being  in  the  shadow),  by 
contra.st  will  appear  green.  Finally,  he  points  to  the  fact  that  a  very  thin, 
transparent  lid,  owing  to  its  great  vascularity,  a  strong  light  })assing 
through  it  into  the  eye,  on  trans-illumination,  will  appear  of  a  purple  color. 
f).  OPTHALMOSCOPICAL  EXAMINATION.  "As  is  well  known, 
jn  the  emmetropic  eye,  the  entire  curvature  of  the  retina  lies  in  the  focal 
plane  of  the  dioptric  system.  According  to  Thomas  Young  this  is  sup- 
posed to  be  due  to  the  lamellar  formation  ..f  the  lens  Hebnlioltz  agrees 
with  the  idea,  and  mere  recently,  owing  to  this  pi-oi)erty  of  the  concentric 
arrangement  in  layers  of  lenses,  Ludimar  Henna:  has  applied  to  them  in 
a  somewhat  different  sense  the  name  "])eriscopic,''  It  is  a  fact,  that  m 
making  the  direct  examination,  even  those  points  in  the  perii)hery.  even 
where  it  is  still  possil)le  to  get  a  view  of  the  fundus,  do  not  give  us  dis- 
torted pictures.  But  I  can  not  agree  with  Donders  when  be  states  that 
we  can  see  the  various  portions  of  the  retina  without  changing  our  accom- 
modation.   The  former  is  caused  by  the  lens,  which  seems  to  be  shown  with 


aT'ber  Erythropsie.     (Jriiefe's  Arch..  XLH..  Part  4.     IWH. 
b  Er.vtliroi)s!e.    Oraef.'-s  .\nli..  XIJV..  Pari  I.     ISitT. 


412 

a  certain  degree  of  certaint}-  by  the  fact,  that  in  aphakia  we  can  onl}-  recog- 
nize the  periphery  of  the  fundus  in  variously  distorted  pictures.  However, 
we  can  not  draw  any  certain  conclusion  from  this,  because  on  the  one 
hand  we  know  that  the  curvature  of  the  cornea  suffers,  as  a  result  of  the 
operation,  and  because  on  the  other  hand  the  capsule  w^hich  is  folded  and 
left  beliind  under  all  circumstances,  causes  an  irregular  astygmatism. 
which  becomes  more  manifest  in  the  periphery  than  m  the  center.'' 

"Donders  quite  to  the  contrary  saw  the  periphery  of  the  fundus  niucli  more 
distinctly  when  the  lens  was  absent  than  when  it  was  present.  And  since,  in 
the  former  ease,  the  peripheral  images  are  also  properly  projected,  he  assumes 
that  in  aphakia  the  indirect  examination  is  so  changed,  that  the  form  of  objects 
in  the  retinal  pictures  are  now  better  seen  with  the  opthalmoscope.  and  hence 
are  less  properly  projected  by  the  eye." 

c.  BINOCULAR  VLSION  IN  APHAKIC  EYES.  "Up  to  the  pres- 
ent time  binocular  vision  in  aphakic  eyes  has  not  been  adequately  investi- 
gated. For  the  little  which  we  do  know  we  are  indebted  to  Von  Graefe 
(807).  The  question  becomes  pre-eminently  a  practical  one,  where  we  are 
to  decide  whether  or  not  we  shall  operate  when  a  cataract  is  present  on 
only  one  eye.  The  question  must  be  answered  variously,  depending  on 
the  fact  whether  the  other  eye  is  still  intact,  hence  able  to  see,  or  whether 
the  second  eye  is  already  attacked  by  cataract  but  is  still  in  a  condition  to 
see.  Aside  from  this,  we  must  take  into  consideration  whether  or  not  the 
eye  to  be  operated  on  promises  a  satisfacton,'  result  as  to  vision.  If  this 
is  not  the  case,  the  operation  is  to  be  made  for  cosmetic  reasons,  and  it 
would  seem  hardly  necessary  to  state  here,  that  everything  depends  on 
whether  it  would  be  i)ractical  to  operate  or  not  under  such  conditions. 

"In  those  cases  in  which  the  second  eye  is  already  afPe<;ted,  it  is  not 
difficult  to  come  to  a  decision.  Nevertheless,  experience  has  taught,  that 
where  two  eyes  see  under  such  different  conditions,  they  disturb  each  other 
verv  mucli  during  the  f.ct  of  seeing.  Each  eye  blends  the  other.  As  long 
as  the  non-operated  eye  answers  all  the  special  demands  for  seeing  on  the 
part  of  the  patient,  he  prefers  to  use  the  non-operated  eye,  especially  for 
near  work;  and  at  times  even  when  the  degree  of  vision  on  the  operated 
eye  is  greater.  This  is  explained  by  the  fact,  that  in  the  operated  eye  much 
illy-refracted  light  enters  the  eye,  which  blends  the  distinct  picture  of  the 
other  eye.  always  assuming  that  \hv  secondary  eataraet  is  woi  a  large  one, 
causing  an  enlarged  retinal  image,  wliieh  without  a  correction  is  a  very 
indistinct  one;  and  lience,  the  patient  finds  liinisell'  in  a  position  similar 
to  that  of  aiiisonieti-o|)ie.  howeviT.  I'eceiving  i-athcr  less  dilViisi'd  light 
than  tlie  non-opei';itc(l  eye."" 

•'ir  ihr  non-o|icr;it('(l  r\v  no  longer  sulliees  for  seeing,  this  over-hleiul- 


4i3 

ing  will  still  take  place.  But  it  loses  its  dislurbinfj  qualities  the  more  the 
cataract  progresses.  Hence,  we  can  often  answer  complaints  with  this  con- 
solation, if  we  do  not  prefer  to  cut  otT'  the  eye  entirely  from  the  act  of  see- 
ing by  placing  an  opaqne  disc  before  it.  Notwithstanding  all  these  draw- 
backs, no  one  should  ever  hesitate  to  operate  a  ripe  cataract  because  the 
otiier  is  not  yet  ripe.  And  indeed  lite  Hiiir  for  (in  opcntUmi  has  (im'red, 
irlicii  ihe  second  affected  eye  hcj/iits  lo  fail  in  ils  scrricc.  Ili'iicc.  we  save 
the  patient,  short  as  this  might  be,  time  of  enforced  idleness.  One  ought, 
with  Graefe,  to  wish  every  person  without  exception,  who  is  affected  with 
cataract,  a  successive  development  of  the  trouble  on  both  eyes." 

"If  we  are  dealing  with  a  cataract  on  the  one  eye,  where  the  other  eye 
shows  no  sign  of  becoming  atfected  in  tlie  s;nne  way.  as  in  a  case  of  cataracta 
iraumatica  or  canrpUcata,  one  must  consider,  that  pfter  even  a  successful 
o])eration,  the  patient  will  have  a  high  degree  of  anisometropia  during  the 
rest  of  his  Lfe.  In  a  certain  proportion  of  these  cases  of  acquired  anisome- 
tropia, and  as  it  occurs  in  congenital  cases,  the  image  on  the  operated  eye 
is  suppressed.  As  a  result  no  absolutely  sharp  fixi.tion  on  the  operated  eye 
takes  place  during  the  act  of  accommodation  and  the  associated  movements. 
Likewise,  by  the  use  ci  prisms,  one  can  neither  bring  about  the  perception 
of  double  images  nor  a  deviation  of  the  visual  line.  (V.  Graefe.)  Investi- 
gations have  not  as  yet  been  made  to  lind  out  whether  or  not  these  occur 
in  eyes  which  before  the  cataract  operation  had  perfect  binocular  vision. 
In  another  percentage  of  cases  Von  Graefe  found  that  true  binocular  vision 
did  occur,  without  causing  the  patient  any  particular  annoyance,  notwith- 
standing the  enormous  difference  in  the  refractive  condition  of  the  two 
eyes.  If  the  fixation  is  absolutely  correct,  the  eye  will  turn  inward  in  using 
an  adducting  prism,  and  it  will  turn  outward  behind  an  abducting  prism. 
Stereoscopic  vision  is  present,  and  distance  can  be  properly  judged." 

•"Up  to  the  present  time  I  have  only  had  one  patient  under  observa- 
tion who  could  be  used  for  making  these  experiments — the  young  colleague 
whom  I  have  so  repeatedly  mentioned.  I  can  positively  assert,  that  during 
complete  and  accurate  fixation  he  was  not  disturbed  in  the  least  by  the 
difference  in  the  size  of  tlu'  images.  The  use  of  prism  gave  the  same  results, 
and  he  was  not  aware  of  any  difference  in  his  ability  to  Judge  distances 
and  in  looking  at  stereoscopic  pictures.  I  regret,  however,  that  I  have  not 
been  enabled  to  make  any  more  exact  experiments.  Hence,  thio  very  inter- 
esting subject  is  still  to  be  investigated." 

"Though  such  successful  eases  are  to  he  looked  upon  as  exceptional. one 
must  nevertheless?  emphasize  the  fact,  that  no  <lisadvar.tao-e  has  as  yet  been 
absolutely  proven  against  such  an  operation.  Tiiu\  we  have  stated,  that 
the  other  eve  is  blended.     Kveu  in  those  ea<<'s  in  wliicli   it   is  present,  the 


414 

patients  become  accustomed  to  it,  in  the  course  of  a  few  weeks.  It  is  said 
that  not  infrequently  strabismus  appears  on  the  operated  eye.  This  does 
occur,  but  it  certain!}-  is  dependent  on  a  disturbance  of  the  muscular  bal- 
ance which  must  have  existed  before  the  operation.  If  it  should  occur,  a 
tenotomie  will  correct  it.  Finally,  the  cry  against  a  one-sided  operation  is 
raised,  of  the  occasional  occurrence  of  diplopia,  a  condition  which,  accord- 
ing to  Von  Graefe,  is  but  exceedingly  seldom  noted." 

"After  all  this,  there  can  be  no  real  disadvantage.  If  we  will  but  for 
the  time  set  aside  those  exceptionally  successful  cases,  in  which  a  really 
binocular  vision  is  attained,  a  mere  cosmetic  result  ought  to  favor  the  oper- 
ation; but  above  all,  the  enlarging  of  the  binocular  field  of  vision  on  the  side 
of  the  operated  e.i/e.  Firstly,  the  latter  at  least  prevents  the  development 
of  the  pathognomic  one-eyed  position  of  the  head.  (That  is,  a  turning  of 
the  head  toward  the  side  of  the  blind  eye,  and  the  eye  turns  toward  the 
side  of  the  seeing  eye.)  Secondly,  the  patient  preserves  the  power  of  locat- 
ing objects  correctly.  Since  in  binocular  Vision,  with  two  healthy  eyes 
we  only  obtain  very  imperfect  retinal  imager,  outside  of  the  horopter,  hence 
in  acquired  anisometropia  the  inaccurate  pictures  in  the  periphery  of  the 
retina  suffice  to  permit  us  to  exercise  proper  judgment  as  to  the  relative 
lateral  displacement  ai.d  depth  of  surfaces;  notwithstanding  the  fact  that 
the  retinal  images  in  both  eyes  do  not  fall  upon  identical  points." 

d.  AMBYOPIA  EX  ANOPSIA.  "An  interesting  fact  is  brought  to 
our  notice,  when  a  cataract  which  has  existed  for  a  long  time  is  finally 
extracted.  Graefe  relates  a  case  in  which  an  operation  was  finally 
made  after  a  cataract  had  existed  for  sixty  years,  and  in  which  excellent 
vision  was  attained.  Becker  operated  a  woman  68  years  of  age,  who  had  a 
catar acta  traumatica  accreta,  wliich  had  existed  since  her  third  year.  The 
operation  was  done  after  the  other  eye  had  been  lost,  as  a  result  of  hypopyon 
keratitis,  and  the  vision  attained  was  exceedingly  satisfactory;  the  woman 
was  able  to  pray  again,  hence  read  in  her  prayer  book.  Analogous  cases 
certainly  come  under  the  observation  of  every  operator."    • 

"The  cases  in  which  such  good  results  are  attained  are  usually  cases  of 
traumatic  origin.  As  is  well  known,  vision  is  nearly  always  very  much 
reduced  in  cases  of  congenital  cataracts,  especially  when  they  are  compli- 
cated by  nystagmus." 

An  interesting  .vludy.  is  Ihr  cdiualinn  of  sujhl  in  those  eongenitally 
blind  from  congenital  cataract.  Here,  after  a  successful  operation,  the 
patient  sees,  but  can  not  recognize  the  objects  seen  until  after  sight  has 
been  educated  by  the  employment  of  the  senses,  such  as  touch.  Thus,  the 
patient  is  shown"  a  key— sees  it  plainly,  but  does  not  recognize  the  object- 
but  let  him  touch  it",  and  he  will  at  once  say,  that  is  a  key.  The  object 
once  recoo-niz,..!  l.v  the  aid  of  other  sonsos,  is  ever  after  recogni/od  on  sight. 


LITERATURE. 


1532.      1.   Arluinis.  .1.  1'..  Dc  sutTusiouc,  (lUMiii  (•:it:ir:ictiiiii  aiMH'llMUt.     M.-diol.-uii. 
1574.      2.   LelJrand   Xicol.,   et   Lamlun-t.   Nicol.,   Noii  «'r^n  sut1\isioinnn   oninium 
eadem  fst  curatio.     Paris. 

1600.  3.  Laurentius,    Aiidr.,    Discours  de  la   c-oHscivatioii  do   la   vuo.      I'aris. 

(Handelt  vom  grauen  Staar.) 

1601.  4.  Moller,  S.,  Diss  de  suffusione,    Fraucof.  ad  Viadr. 

1649.      5.  Fienus,  Th.,   De  praecipuis  artis  chirursicae  controversiis.    Lib.   II. 

De  cataracta.    Francof. 
1664.      0.  Kolflnk.  Werner,  Disp.  de  cataracta.    Jeua. 

7.  Bartholinus,  Th.,  De  oculorum  suffusione  epistola.     Ilafniae. 
1670.      8.  Friderici.  J.  A..  Disp  de  suffusione.     Jenae. 

9.  Meibom.  .T.  H.  (.T.  G.  Rose),  Disp.  de  cataracta.     Helmstadt. 
10.  Anonym.,  Lcttre  sur  une  nouvel  le  opinion  an  su.1»4de  la  cataracta. 
Rouen. 
1675.    11.  Harder,  M.,  Disp.  de  cataracta.     Basil. 
1672.    12.  Niemand,  H.,  Disp.  de  suffusione.     Argentorati. 
1684.    13.  Sperling.  P.  G.,  Aeger  suffusione  laborans.     Jenae. 

14.  Papelier,  J.  E.,  Aeger  suffusione  laborans.     Argent. 
1688.    15.  Felir.  .1.  L.,  Cataractae  depositio  in  utroque  oculo  feliciter  celebrata. 

Misc.  Ac.  Nat.  Cur.,  Dec.  2. 
1691.    16.  Pechlin  et  Dreliniour,  Verknoclierte  Linse.  in  Pecliliu  observ.  phys. 
lued.,  p.  296.     Hambiu-g. 
17.  Schelhamnier,  G.  C,  Disp.  de  suffusione.     Jenae. 
1695.    18.  Albinus,  B..  resp.  L.  D.  Gosky,  Disp.  de  cataracta.    Francof.  ad  Viadr. 
und  Lugd.,  Bat.  1738.     Halleri  Bibl.  Chirurg.,  I,  p.  4.50  u.    Halleri 
Disp.  Chirurg.  select,  torn.  II.    Lausanae,  1755. 
1700.    19.  De  la  Hire,  Phil.,  Tract  de  cataracta.    Parisiis.  (?) 
1704.    20.  Schacher,  P.  G.,  Diss,  de  cataracta.     Lipsiac. 

1706.  21.  Wedel.  G.  W.,  Disp.  de  cataracta.     Jenae. 

22.  De  la  Hire,  Phil.,  Tr.  de  cataracta.     Paris. 

23.  Brisseau,  P.,  Traite  de  la  eataracte  et  la  glaucoma.     Tournay.  , 

24.  Histoire  de  I'Acad.  Royale  des  Sciences.    (1)  De  la  Hire.  Sur  les  cata- 

ractes  des  yeux,  p.  12.     (2)  De  la  Hire.  Sur  la  nature  des  cata- 
ractes  qui  se  forment  dans  I'oeil.  p.  20 

25.  Lang.  C.  J..  Diss,  de  cataracta.    Paris. 

1707.  26.  Maitre-Jean  Antoine,  Traite  des  maladies  des  yeux.    Paris. 

27.  Hist,  de  I'Acad.  Roy.  des  Sciences.  (1)  Sur  les  cataractes  des  yeux, 
p.  32.  (2)  Mei-y.  Si  le  Glaucoma  et  la  eataracte  sont  deux  differ- 
entes  ou  une  seule  et  meme  maladie.  p.  491.  (.3)  De  la  Hire  le  tils. 
Remarques  sur  le  eataracte  et  le  glaucoma,  p.  550. 


31. 

1709. 

32. 

33. 

1710. 

34. 

1711. 

35 

4i6 

3708.  28.  Histoire  de  I'Acad.  Roy.  des  Sciences.  (1)  Sur  les  cataractes  des 
yeux,  p.  39.  (2)  Mery  de  la  cataracte  et  du  glaucoma,  p.  241.  (3) 
De  la  Hire  le  tils.  Remarques  sur  la  cataracte  et  le  glaucoma,  p. 
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29.  Jacobi.  L.  Fr.,  Disp.  de  cataractae  nova  pathologia.    Giford. 

30.  liCFrancois,  Alexander  et  J.  N.  de  la  Hire.  Ergo  potest  stare  visio 

absque  crystalline.     Paris. 
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.  Traite  de  la  cataracte  et  du  glaucome.     Paris. 

Mery.  Jean,  Observation  sur  un  glaucoma  cru  cataracte.     Histoire  de 

I'Acad.  Royale  des  Sciences. 
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Lusardi,   Dissert  sur  I'opacite  du  crista llin  et   sur  I'operation  de  la 
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37.  Camerarius,  E.,  De  nova  cataractae  theoria.    In  epistolis  Taurinensi- 
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Altorf,  1711,  1712.  1743,  resp.    Widman.  Vogt  et  Paul!. 

40.  ,  De  cataracta  et  de  mira  paralysi.    Ephemer.  Ac.  nat.  Cur.  Out. 

1  et  2,  1712. 

41. .  De  cataracta  quadani  lactea  rara  et  singulari  in  dissecto  oculo 

observata.     Ephemer,  Ac.  Nat.  Cur.  Cent.,  4  et  5,  1715. 

42. ,  Tract,  de  cataracta.  glaucomate  et  amaurosi.    Altorf.  1713:  ed. 

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43. ,  Apologia  sy«tematis  sui  de  catar..  glaucom.  et  amaurosi  contra 

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Gakeuholz.  A.Chr..  Disp.  de  visione  per  cataractam  impedita.  Helmst. 
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44 

713. 

45 

L714. 

40 

715. 

47 

48 

417 
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63.  Benevoli,  Ant.,  Lettere  sopra  due  osservazioni  fatte  intoruo  alia  cata- 

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66.  Roberg,  L.,  Disp.  de  cataracta.     Upsal. 

67.  Pinson,  Observations  sur  la  cataracte  et  le  glaucoma.    Dictees  a  Mr. 

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68.  Deidier,  Lettre  ecrite  a  Mons.  Woolhouse,  ibidem,  p.  80.    (Beschreibt 

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,i;i 

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l>i 

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1828.  387.   Somniering.   W..   Beobachtungeu   uber  die  organisclien   Veranderun- 

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388.  Ammon,  A.  v.,  Ueber  die  angeborene  cataracta  centralis.     Graefe  u. 

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389.  Seliger,  Uebersucht  der  verschiedeuen  Staar  ausziehungsmethoden, 

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390.  Appiani,  Dissert,  de  phacoliynienitide.    Fienni. 

391.  Breton.   Bericht  uber  die   bei   den   Eiugebornen   von   Ostindien  ge- 

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392.  Placer.  J.,  Diss,  de  (iitarM«t;i  et  iionnullis  eaiii  exiraliendi  methodis. 
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433 

1828.  393.  Gondrot.  L.,  Mem.  sur  h'  tiaiteim>nt  de  la  i-aiaractc.    Bd.  3.    Paris. 

1829.  394.  Nieberding,  F.  A.,  Diss,  de  diversannn  cataractae  curandae  method- 

oruni  indicatiouibus.     Berol. 

395.  Meyer,  II.,  Diss,  sistens  cataractae  operationom  pcrficiendi   meth- 

odiium,  qua  ulitur  C.  Himly.    Rostodi. 

396.  Ott,   F.   A.,    Diss,   de  nova  Jacgeri   cataractam  cxtraliendi   ratione. 

Straubing. 

397.  Bancal,  Manuel  pratique  lithotritic,  suivi  duu  uiemoire  sur  la  cata- 

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1830.  398.  Frey,  J.  M.,  Diss,  de  cataracta.     Berol. 

399.  Closset,  G.  A.,  Diss,  sistens  quaedam  de  praecipuis  uiorbis,  qui  post 

opera^Jonem  cataractae  oriri  possunt.     Berol. 

400.  Rosenmuller.   F.  A.,  Diss,  de  staphylouiate  scleroticae  nee  non  de 

melanosi  et  cataracta  nigra  nonnulla  adhibcns.     Erlangae. 

401.  Rosas,  Handbucb  der  Augenbeilkunde.  1,  III.    Wien. 

402.  Bech,  Dissert,  de  cataracta  centrali:     Lips. 

403.  Ammon,  v.,  Ueber  den  krankhaften  consens  der  Hornhaut,  der  krys- 

tallinse  und  ihrer  Kapsel.    Z,  f.  d.  O.,  I,  p.  119. 

1831.  404.  Schmidt,  J.  A.,  A' on  der  cataracta  y.  Amnion's  Z.  f.  d.  O.  I,  p.  350. 

405.  Schon,  Ueber  den  marasmus  senilis  der  kapsel  und  linse  im  mensch- 

licben  auge.     Ibid. 

406.  Lochia,  Wutzer,  Jahn,  Ueber  Coloboma  iridis  mit  gleichzeitiger  cat- 

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407.  Ammon.    v.,    Spontaner   Yorfall   einer    Krystallinse   in    die    vodere 

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408.  Gescheidt,  Colobomo  iridis  mit  Partialtnibung  der  Linse  (c.  I.  cen- 

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1832.  409.  Warnatz,  Dissert,  de  cataracta  nigra.     Lips. 

410,  ,  Die  schwarz  gefarbte  anderen  ahnlichen  augenkrankheiten. 

Z.  f.  d.  O.  II,  p.  295. 

411,  Ullmann.    Spontaner   Yorfall   einer   Augenkammer   und   entfernung 

derselbe  durch  die  extraction.    Z.  f.  d.  O.  II,  p.  129. 

412,  Ammon,  v.,  Zur  pathol.  Anatomic  der  Fossa  hyaloidea  im  meusch- 

lichen  Auge.     Z.  f.  d.  O.  II,  p.  388. 

41.'>. .  Prof.  Rosas'  Ansichten  uber  die  Sehversuchi'  gleich  uach  voll- 

zogener  Extraction  des  Staares.     Z.  F..  d.  o.,  p.  4(KI. 

414.  Dupuytreu,  Bemerkungen  uber  den  grauen  Staar.     Mitgetheilt  von 

Behr.    Z.  f.  d.  O.  II,  p.  460. 

415.  Arnold,  F.,  Anatom.  Untersucliungeu  uber  das  Auge  des  Menschen. 

416.  Schmidt,  Aemil,   Diss,  de  Keratotomia   sursum  vorgente  secundum 

Jaegeri  methodum.     Berol. 

417.  Carron  du  Villards,  Ch.  J.  F..  Lettre  a  Mr.  Mauuoir  sur  un  nouvel 

instrument  destine  a  rectifier  ou  aggrandir  I'incision  de  la  cornee 
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434 

1832.  418.  Amniou.  v..   Venlickunj;  und  Verwachsunjr  thn-  Art.  centralis  o<uli 

als  Ursache  des  Ceutralstaars  der  Kapsel  iiud  Linse.  und  zur 
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1833.  419.  Beck.  De  ociilorum  miitationibus,  quae  cataractae  operationem  se- 

quuntur.  observatio.  aduexis  corollariis.    Freib.    Deutsch  von  Be- 
ger  in  von  Amnion's  ZeitscLr..  f.  d.  O.,  Bd.  4. 
42(t.  Amnion,  v..  Der  angeborene  Staar  in  path.,  anat..  in  pathogen,  und 
in  operativer  Hinsicht.    Z.  f.  d.  O.  Ill,  70. 

421.  ,  Operation  des  grauen  Staars  an  einciii  Alttiiio.     Z.   f.  d.   O. 

Ill,  p.  116. 

422.  Beger.  Ueber  die  Ver-vvundbarkeit  (h's  Auges  und  seiner  Haute.    Z. 

f.  d.  O.  III.  p.  145. 

423.  Heidenreich.    Schwarze   cataracte    niit    weissem    exsudate    auf   der 

kapsel.    Z.  f.  d.  O.  II,  p.  205. 

424.  Werueck.  Zur  Aetiologie  und  Genesis  des  grauen  Staars.     Z.  f.  d.  O. 

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425.  Mannoir.  Th..  Essai  sur  quehiues  p(»ints  de  IMiistoire  de  la  cataracte. 

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42G.  Rast.  De  variis  cataractae  opera ndae  methodis.    Solinb. 

427.  Bergeon.   G.   C,   De  la  reclinatiou  capsulo-lenticulaire.   ou  nouveau 

precede  d'abaissenient  de  la  cataracte  avec  aiguille  nouvelle. 
These.    Paris. 

428.  Lattier  de  la  Roche,  Mem.  sur  la  cataracte  et  guerison  de  cette  mal- 

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1834.  429.  Deutsch.  u.  d.  T.,  Beobachtungen  und  Erfahrungen  uber  die  Heilung 

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430.  Carron  du   Villa rds,  Recherches  pratiques  sur  les  causes  qui  font 

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431.  Kyll,  Geschichte  einer  freiwilligen  Zerreissung  der  Cornea  und  He- 

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432.  Starrhetti,  Partieller  Vorfall  einer  durchsichtigen  Krystallinse.     Z. 

f.  d.  O.  IV,  p.  463. 

433.  Dupuytren,  G..  Von  der  Cataracta.     Kliniscli-cliirurg.    Vortrage  fur 

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434.  Rineclier,   Fr.,   Entzundung  der  Gefass,   Xerven  und   Glasliaut  des 

Auges  und  ihr  Ausgang  in  das  hintere  Eiterauge,  in  Folge  der 
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1835.  435.  Warnatz,  Resorptio  citarMctae  spontanae.    V.   .Vniiiu.n's  Z.   f.  d.  O.. 

V.  p.  49. 

436.  liorcli.   Von  «'inigen  durcli  Naturlmlt'e  gelioheiieii  .\ugenkrankheiten. 

Z.  f.  d.   ().   IV.  p.  3S. 

437.  Schon.  .Marasmus  senilis  dei-  Kapsel  und  der  Linse.    W  Animon's  Z. 

f.   d.   U.    IV.   p.   73. 


435 
1830.    4;kS.    Koll.ir,   .1.,    I»iss.   dc   praccipiiis    iiioil)is    pcist    cMtiiracta   openitionem 
sfc-iidariis.      \ratislav. 
4;;!>.    Kcfkcr.  Tli.,  A.   1'..   Diss.  <!(•  aiiibijiuc  (I'K'iii'xl'""  n'criitioruiii   kora- 
totoinoruni  praestantia.     Lips. 

440.  Rtnit*',   Vorbessertes  Verfalirt'ii   ln-i  dcr  Sclci-oticdiiy.xis.      ITolscher's 

.\iiii.  f.  (1.  (Ji'sauimte  IltMlkimdc.  1.  III. 

441.  I'liii*'!'.    Aiiszieliunj;   zweior   Cataracten    aus    aniaiirolisclicn    Augen. 

Z.  f.  (1.  O.  T,  p.  357. 

442.  Jaeger  (Rinecker),   Geschiclite  eincr   Kiitziiiidiinir  der  Ader-Nerven 

und  (Jlnsliaut  iiiul  iliros  Ausgaugcs  in  das  hintere  Eiteraugo  in 
Folge  der  Niederdruckung  des  Staars,  iiebst  anatoniiscb  patbolo- 
gisi-lier  rntersuclnuig  des  Auges.     Z.  f.  d.  (>.  V.  \).  :\7,s. 

443.  Comperet.  These  svir  la  eatanicte,  I'aris. 

444.  Unger,  Operation  einer  Cataract   bci  glwcli  zeitig  bestehender  Harn- 

rulir.  7..  t'.,  d.  ().  v.,  p.  356. 

1837.  445.  Siehel.  Traite  de  ropthalniie.  la  cataraete  et  Tauianrose.     Paris,  in 

So.  p.  7,-»(). 
44<;.  Carron  dn  Ylllards.  Keeherches  medico-eliirurgicales  sur  I'operation 
de  la  cataraete,  les  luoyeus  de  la  rendre  plus  sure  et  sur  I'inutilite 
des  traitements  medicaux  pour  la  guerir  sans  operation.     Paris, 
in  8o,  p.  423. 

1838.  447.  Burkhardt,  Appreciation  physiologique  de  deux  cas  de  luxation  du 

cristallin.  Ber.  der  Xaturf.  (ies.  in  Basel  u.  Ann.  d'Ocul..  XXX. 
p.  114. 

448.  Onsenoort,  van  Geseli,  der  Augenh.  als  enleitung  in  d.  Studium  der- 
selben.    Deutscli  von  Wutzer. 

44;».  Pauli.  F.,  Sublatio  cataractae,  eine  neue  luetliode  den  grauen  Staar 
zu  operiren.    V.  Ammon,  Monatssclir..  I,  p.  97. 

4.50.  Benedict.  Bemerkungen  uber  einige  neuere  Enclieiresen  znr  Erleich- 
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451.  Pauli,  F.,  Ueber  den  grauen  Staar  und  die  Verkrummungen  und  eine 
neue  Hellart  dieser  Krankheit.    Stuttg.,  in  So,  p.  439. 

4.52.  Beck,  Ueber  die  entstebuug  der  cat.  caps,  anterior.    V.  Ammon,  Mo- 
natssclir. f.  INIedicin,  Augenheilk.  u.  Cbirurg.,  t.  II. 

453.  Stoeber.  Observations    des    cataractes    traumatiques,  addressees    a 
I'Acad.  Roy.  de  Med.  de  Paris.    Ann.  d'Ocul.,  III.  p.  (54. 

4.54.  Loewenhardt,  Resorption  d'une  cataract  au  moyen  d'un  seton  passe 
a  travers  le  sristallin  opacpie.     Ann.  d'Ocul.,  I,  p.  20. 

455.  Cunier,  Du  displacement  spontane  du  cristallui.  Ann.  d'Ocul..  I,  p.  59. 

4.50,  Carron  du  Villa rds.  Du  deplacement  du  cristallin.    Ibid.,  t.  I,  p.  74. 

457,  Petrequin,  Nouvelles  remarques  sur  Toperation  de  la  cataraete  par 
I'abaissement,    Ibid,,  I,  d.  157. 
1839.    4.58.  Lombard,  Considerations  et  observations  sur  la  guerlson  des  cata- 
ractes et  des  effections  de  la  cornee  transparente  par  une  methode 
resolutive,  etc.     Paris,  in  So.  p.  SO. 


436 

1839.     459.  Furnari,  Essai  sur  uue  uouvelle  methode  d'operer  la  cataracte  par 
rextraclion  par  la  sclerotique.    Paris,  in  8o,  p.  16. 
460.  Bron,  Traitement  homoeopath ique  de  la  cataracte.    Ann.  d'Ocul.,  II, 
p.  218. 

4(;i. .   Cataracte  leuticulaire  gueric  iKir  le  cannabis  sativa.     Ibid., 

p.  181. 

462.  Pauli,  Ein  beitrag  zur  Lehre  von  der  Heprodnction  der  Linse.     V. 

Ammon,  Monatsschr.,  II,  p.  84. 

463.  Averdam,  B.  H.  J..  Diss,  de  cataracte.    Berol. 

464.  M.  X.,  Quelle  est  I'influence  qu'  exerce  I'operation  de  la  cataracte 

sur  la  vie  de  ceux  pui  la  subissent.    Ann.  d'Ocul.,  H.,  p.  57. 

465.  Onsenoort,   van,    Deplacement   du   cristallin   suite   d'une   lesion   re- 

marquable'de  Toeil.    Ann.  d'Ocul.,  II,  p.  138. 

1840.  466.  Stocher,  A^,Observations  de  cataractes  traumatiques.     Ann.  d'Ocul., 

T.  3. 

467.  Drouot,  F.,  Nouveau  traite  des  cataractes,  causes,  symptomes,  com- 

plications et  traitement  des  alterations  du  cristallin  et  de  la  cap- 
sule sans  operations  chirurgicales.    Bordeaux. 

468.  Sichel,  Methode  simple  et  facile  de  faire  des  cataractes  artificielles. 

Ann.  d'Ocul.,   IV,  p.   147. 
4»59.  Tyrell,  A  praTctical  wwk  on  the  diseases  of  the  eye  and  their  treat- 
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1841.  470.  Hoeriug,  G.,  Ueber  die  Dislaceratio  capsulae.  nach  .Tager.   Wurtemb. 

Med.  Corresp.,  B.  1,  No.  8. 

471.  Dittrich,  Dissert,  sistens  couspectum  cataractarum,  in  clinico  et  con- 

•  signatione  opthalmiatrica  operatorum.     Pragae.  in  8o. 

472.  Sichel,   De  la  cataracte  glaucomateuse.   de  I'inutilite  et  des  suites 

facheuses  de  son  operation.     .\nn.  d'Ocul.,  V,  p.  232. 

473.  Malgaigne,  Opinion  sur  la  nature  et  le  siege  de  la  cataracte.     Ibid., 

VI,  p.  62. 

474.  Lerche,  Ueber  die  Heilwirliuug  des  Galvanismus  in  einigen  organ- 

ischen  Augenkranliheiten   (Cataracta).     Zeitschr.,  d.   V.  f.   Heil- 
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475.  Ounier,   Comptc   rendu.   XXII.     Cataracte   verte.  "Ann.   d'Ocul.,   V, 

p.  249. 

476.  Fahl,  G.  R.  J.,  Diss,  de  praecipuis  morbis.  <iui  cataractae  operationes 

sequi  possunt.     Berolini. 

477.  Stromeyer.  C,  Das  corektom.  ein  neues  instrument  fur  kunstliche 

pupillenbildung  imd  fur  die  extraction  des  angewachsenen  Staars. 
Allg.  Ztschr.  f.  Chirurg.,  No.  22. 

1842.  478.  Guepin,  Note  sur  la  nature  et  la  formation  des  cataractes.     Ann. 

d'Ocul.,  VI,  p.  203. 
479.  Serre  (de  Montpellicr),   De  roperation  d<^  hi   cataracte  sur  un  oeil, 
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437 
1842.    480.   Hocrinj.',  C.  stir  W  sirp"  <•!   l.i   iiMiiin'  di-  ia  calaracte.     Ibid.,  VIII. 

p.  i:;. 

481.  Su'lH'l.   Etudos  cliniqiu's  ct  auati.iiii(ivi.-s  sur  qiichiucs  especes  pen 

connuos  do  la  cataracte  k'ntit-ulaiiv.     Ann.  d'Ocnl..  VIII,  p.  127. 

482.  Benedict,  Kinigo  Benierknngon  uIht  die  aeti(.Iogie  der  cataracta  u. 

s.  w.,  abhandlungeu  us  deui  Uebiete  der  Augenheillainde.    Bres- 
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48:5.  Textor,  Tber  die  Wiedererzengung  der  Krystallinse.    Wurzb.  in  8o. 

484.  Blashis,    Nouveau   procede   de    l'extra<-tion   de  la   cataracte.     Ann. 

d'Ocul.,  IX,  p.  34. 

485.  Sanson.  Traitf  de  la  catanicif.     Paris,  in  So. 

486.  Engel.  I'ntersiu-limig  eines  kapsclstaars.    Ot'Sti-ir.  Med.  Woclienschr. 

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487.  Straucli,  Mitilieiluugen  uber  den  GalvanisnniM  als  Mittel  gegen  den 

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488.  Szokalski,  v..  Reflexions  au  sujet  de  la  note  de  Mr.  Guepin.  sur  la 

nature  et  le  siege  de  la  cataracte.    Ann.  d'Ocul..  VI. 

489.  — ■ ,  Response  to  Mr.  Guepin.     Ebenda. 

490.  S.  van  der  I'orten.  Diss,  de  cataractae  extractioue  adjecta  nova  ex- 

trahendi  ratione.    Halae. 

491.  Benedict,  F.  VT.  G.,  Ueber  die  sog.  cat.  nigra  und  deren  diagnose. 

Ueber  cataracta  gjpsae;  ueber  die  beliandlung  der  entstehenden 
cataract.    Abhandlungeu  a.  d.  Geb.  d.  Augenheilkunde.    Breslau. 

492.  Petrequin.  J.  E..  Mem.  sur  un  nouveau  procede  pour  Toperation  de 

la  cataracte  per  extraction.     Ann.  d'Ocul.,  VI,  p.  193. 

493.  Bernard,  P.,  Cat.  operee  par  la  methode  sous-conjunctivale.    Ebenda 

VII. 

494.  Freund,  Die  operation  des  grauen  Staars,  wie  diese  gegenwartig  von 

Englands  voi-zuglichsten  Aerzten  auzgetulu-t  wird.     Allg.   Med. 
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496.  Sichel,  Lettre  sur  la  nature  et  le  siege  de  la  cataracte.    Ann.  d'Ocul., 

VI,  p.  64. 

497.  Leroy  D'Etiolles.  Lettre  sur  la   nature  et  le  siegr  de  la  cataracte. 

Ann.  d'Ocul.,  VI,  p.  70. 

498.  Heyfelder,   Das  chirurgische  und  augenkranken-klinicum   der  Uni- 

versitat  Erlangen.  vom  1  Oct.,  1841.  bis  30  Sept..  1842.  Heidel- 
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438 
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501.  (tuIz.    Velpeau's    extraction    des    grauen    Staars    am    leehten    auge. 

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und  V.  Ammon's  Joiirn.,  II.  St.  4. 

509.  Fronmuller,  Sonderbare  Eutstebung  einer  Cataract.     Ibid.,  St.  2. 
.jlO.  .Tans.  Cataraete  operee  avec  sueces  chez  une  femme  aveugle  depuis 

Aingt  cinq  ans.     Ann.  d'Ocul.,  X,  p.  128. 

511.  Stafford,  Cataraete  congenitale,  operee  chez  un  sujet  de  23  ans.   Ann. 

d'OsHd.,  X,  p.  143. 

512.  Mackenzie,  Cataraete  lenticulaire,  operee  par  extraction.    Section  de 

la  cornee  au  moyen  d'un  couteau-aigullle.  reniarques  sur  les  cou- 
teaux-aiguilles.    Ann.  d'Ocul.,  X,  p.  209. 

513.  Rigler.  Note  sur  I'anatomie  pathologique  de  la  cataraete.  a  propos 

de  la  discussion  survenue  entre  Mons.  Guepin  et  Szokalski.   Ann. 
d'Ocul.,  X,  p.  220. 

514.  Boling.  Cataraete  operee  avec  sueces  sur  un  vieillard  de  110  ans. 

American  Jotirnal. 

515.  :Mannoir.  Mem.  sur  les  causes  de  non-succes  dans  I'operation  de  la 

cataraete   par  extraction    et    des     moyens  d'y    remedier.     Ann. 
d'Ocul.,  II. 

510.  Boulogne,  A.,  Mem.  sur  deux  instruments  nouveaux,  destines  a  Tex- 

traction  et  a  I'abaissement  de  la  cataraete.    Marseille. 
517.  Sichel,  .T.,  Etudes  eliniques  et  anatomiques  sur  quelques  especes  peu 

connues  de  la  cataraete  lenticulaire.     Ann.  d'Ocul..  VIII.  p.  109. 

(Fortsetzung.) 
.518.  Drauot,  Des  erreurs  des  oculistes  sur  la  cataraete.  I'amaurose  et  les 

traitemens  opposes  a  les  affections.     Paris. 
1843.    519.  Gluge,  Note  sur  rossifleation  du  cristalliu.     Ann.  d'Ocul..  X.  p.  220. 
.520.  Bonehaeourt.  Observations  sur  les  concretions  calcaires  dans  roeil. 

Cont.  les  petrifactions  de  la  lentille.     Ann.  d'Ocul..  X,  p.  250. 
521.  Guepin.   Quelle  conduite   faut-il    tenir  dans  les  catanictes  etroites. 

eongenitales  ou  autres'/    I>\MUl-il  dans  I'operation  de  la  cataraete 

presser  sur  I'oeil  pour  la  ire  sortir  le  cristallin?    Response  a  la 

lettre  de  Mons.  le  Doct.     Rigler.     Ann.  d'O.ul..  X,  p.  291. 


439 

1844.    522.  Hooriu^-,  (!..  FoIht  .leu  Sit/,  un.l  .li.-  nalur  d.-s  ^Mnvion  Staars.    Eine 

von  der  Redactiou   dor   Annali's   d'Oculistiquf   (;«'kront.'    Prelss- 

schrift.    Hoilbronu.  1844. 

.-)2:;.  Duval  (d-AKontan).   De  la  t-ataracto  srcondaiic     Ann.  d'()<ul..  XI, 

pp.  5,  61.  170  uud  209. 

524.  Fleckles.  Ileilung  einer  cataract  duivh  (li»>  ('arlsba<k'r  Ileilquellen. 

Hufeland's  Jouru.,  Mars. 

525.  Sichel.  Observations  et  considerations  snpplcnicntaires  sur  le  glau- 

coma et  la  cataracte  glaucomateuse.    Ann.  d'Ocul..  XI,  p.  157. 
1844.    52(5.  Scott.   Cataract  and  its  treatment,  comprising  an  easy  method  of 
dividing  the  cornea  for  its  extraction,  etc.     London.    British  et 
Foreign  Med.  Review.     April. 

527.  Jager,    Eduard.   Ueber  die  Beliandlnng  des  grauen   Staars  an   der 

opthalmol.     Klinik  der  Josephs  Aeedemie.     Wien. 

528.  Mirault  (d'Angers),   Sur  la  cataracte  capsulaire   secondaire.     Ann. 

d'Ocul.,  XII,  p.  731. 
52!>.  Landrun.  .1.  F.  P.,  De  la  kistotomie  posterieure  on  dechirement  de 

la  crystalloide  posterieure  apres  I'extraction.   comme  moyen  de 

s'opposer  aux  cataractes  membraneuses  secondaires.     Paris. 
5.W.  Pamard.  Memoires  de  chirurgie  pratique,  conten.  la  cataracte.  I'iritis 

et  les  fractures  du  col  de  Temur.    Paris. 
->?,!.  Duesing,  Das  Krystalliusensystem  des-menschlichen  auges  in  physi- 

ologischer  und  pathologischer  Hinsicht.    Berlin. 
532.  Pamard,  De  la  cataracte  et  son  extraction  par  un  procede  particulier. 

Ann.  d'Ocul.,  XII,  pp.  149,  191. 

5.33.  Guepin.  A.,  De  la  refraction  de  la  lumiere  dans  Toeil  apres  I'oper- 

ation  de  la  cataracte  par  extraction.    Ann.  d'Ocul.,  VI,  p.  12. 

5.34.  Guthrie,  Observations  cliniques  sur  la  cataracte.    Med.  Times,  Oct. 

et  Dec. 

535.  A.   de   Grand-Boulogne.    Memoire   sur   deux   instruments   nouveaux 

destines  a  I'extraction  et  a  I'abaissement  de  la  cataracte.     Ann. 
d'Ocul.,  XI,  p.  56. 

536.  Blasius,  Sur  une  nouvelle  modification  apportee  an  couteau-aiguille 

pom-  I'extraction  de  la  cataracte.     Ann.  d'Ocul.,  XI,  p.  135. 

537.  Lusardi  (pere).  Response  a  cette  question:   Quelle  est  I'influence  qu' 

exerce  I'operation  de  la  cataracte  su-  la  vie  de  ceux  (pii  la  subis- 
sent.    Ann.  dOcul.,  XI,  p.  145. 

538.  Berard.  De  I'operation  de  la  cataracte  faite  sur  un  seul  oeil.  sans 

attendre  que  la  cataracte  soit  formee  dans  I'oeil  opposee.     Ann. 
d'Ocul..  XI.  p.  179. 

539.  Sichel,    Cas   rare   d'ossification   de   la    capsule   cristalliue   dans   une 

cataract  traumatique.    Ann.  d'Ocul..  XT.  p.  223. 

540.  Szokalski.  Operation  de  cataracte  sur  uii  vicillard  de  103  ans.    Ann. 

d'Ocul..  XI.  p.  272. 


440 

1844.  541.  Abren.  Cristalliu  remonte  et  passe  dans  la  chambre  anterieure,  22 

mois  apres  la  depression  de  la  cataraete.   Ann.  d'Ocul.,  XII,  p.  36. 
.".42.  Tilanus.  Observation  d'iridereniie  eongenitale.  eompliquee  de  cata- 
raete.   Ann.  d'Ocnl.,  XII,  p.  43. 

543.  Abren.  Diss,  snr  un  nouveau  procede  pour  la  reclinaison  depression 

de  la  cataraete  et  snr  les  resultats  obtenus  dans  cette  operation, 
a  I'institut  opthalmique  a  Bruxelles.    Ann.  «.'Ocul.,  XII,  p.  53. 

544.  Turnbnll.  Nouveau  traitement  de  la  cataraete  et  le  quelques  autres 

maladies  des  yeux  sans  operations  chirurgrieales.    Traduit  de  I'an- 
glais  par  lusardi  (pere)  et  Paul  Bernard. 
54.5.  Textor.  De  I'operation  de  la  cataraete  par  keratouyxio.    Ann.  d'Ocul. 

XII.  p.  212. 

54<'..  Fischer.  Eclaircissements  sur  la  relation  qu'  faite  Cheselden  au 
sujet  d'un  jeune  aveugle  de  14  ans  qu'il  opera  il  y  a  pres  de  120 
ans.  Bericht  uber  die  Verhandl.  der  naturf.  Gesellsehaft  zu  Basel. 
1844.  VI.  p.  111.    Ann.  d'Ocul..  XXX.  p.  l-tt. 

1845.  .547.  Strieker.  Die  krankhelten  des  Linsensysteuis  nach  physiol.    Gund- 

satzen,  Frankfurt. 

548.  Frerichs,  Path.  Anatom.  und  Chemische  Untersuchungen  uber  Lin- 

senstaare.     Hann.  Ann.,  Nov.  u.  Dec. 

549.  Desniarres,  De  la  cataraete  pigmenteuse  ou  uveenne  et  son  diag- 

nostic differential.   .Tourn.  de  Chirurg.  de  Malgaigne  et  Ann.  d'Oc, 

XIII,  p.  132. 

550.  Arlt,  Zur  Nosogenic  der  catar.  caps.  cent,  anterior  und  der  catar. 

pyramidalis.     Oesterr.  Med.  Wochenschr.,  No.  10  u.  11. 

551.  Furnari,  De  la  pretendue  inflxience  des  climats  sur  la  production  de 

cataraete  et  de  I'iunocuite  de  la  reverberation  directe  et  de  la 
lumiere  sur  les  uiilieux  refringents  de  Toeil.  Ann.  d'Oc.  XIII. 
p.  158. 

552.  Christiaen,  De  I'extraction  simultanee  du  cristallin  et  de  sa  capsule. 

Ibid.,  p.  181. 

553.  Guthrie.  On  cataract  and  its  appropriate  treatment  by  the  operation 

adapted  for  each  peculiar  case.     London. 
5.54.  Sichel,  Considerations  praticiues  sur  I'extraction  des  corps  etrangers 

inipl.'intes  dans  le  cristallin.    Ann.  d'Oc,  XIII,  p.  193. 
555.  .   Etudes  diniques  sur  I'operation  de  la  cataraete.    Gaz.   des 

Hopitaux  et  Ann.  d'Oc,  XIV,  p]>.  75.  Ill,  155. 
5.50.  Boux,  Generalities  snr  les  deux  procedes  (r<)i)eration  de  la  cataraete. 

Ibid.,  XIV,  p.  177. 

557.  Serre  (de  Monlpellieri.  Oi>eration  de  la  cataraete  selon  la  methode 

par  deplacement.  faite  avec  succes  apres  soixante  ans  de  cecite. 
Ann.  d'Oc,  XIV,  p.  224. 

558.  Dubois  (de  Neufchatel).  Operation  de  la  catarai'te  datant  de  44  ans. 

suivie  de  retablissenient  de  la  vue.  (iaz.  Med.  et  Ann.  d'Oc,  XIV, 
p.   229. 


k 


441 

1845.    559.  Gerold.  Ueber  cataracta  uatatllis  uud  lui.    Moifiasiii.    /eitschr.  des 
Vereins  fur  Heilkunde  in  Preussen,  No.  25. 
560.  Coopor,  Remarques  siir  Textraction  de  la  oataracte.     Pro  v.  Journ, 

.Tuin. 
5(il.  Hervez  de  Chegoin,   De  I'operatioii   de   l:i    eataracte  par  <'levation. 
Ann.  d'Oc,  XIII.  p.  37. 

562.  Pamard,  Memoires  de  ehirurgie  pratique,  compr.  la  eataracte,  I'iritis 

et  les  fractures  du  col  de  femur.    Paris.     Ann.  d'Oc,  XIII.  p.  83. 
(Fortsetzung.) 

563.  Duval,    Quelques   reflexions    sur    les    premieres    impressions    d"un 

aveugle  ne  rendu  clairvoyant:  suivies  de  considerations  soramaires 
sur  la  maniere  d'operer  les  cataractes  de  naissance  de  differentes 
.  ages.    Ann.  d'Oc,  XIII,  pp.  07  and  241. 

564.  Heyfelder,  De  I'influence  de  la  commotion  sur  I'oeil.     Ann.  d'Oc, 

XIII,  p.    145. 

565.  Vinella,  Ossification  de  la  capsule  du  cristalliu.     Ann.  d'Oc,  XIII, 

p.  279. 

566.  Vogel,   Examen   niicroscopi<iue  d"un   cristallin  opaque.    Ann.   d'Oc, 

XIV,  p.  29. 

567.  Debron,  Nore  sur  le  passage  du  cristallin  dans  la  chambre  anterieure 

pendant  I'operation  de  la  eataracte  par  nbaissement.    Ann.  d'Oc, 
XIV,  p.  32. 

568.  Tavignot.  Abaissement  en  masse  d\\  cristallin  et  de  la  capsule.   Ibid., 

p.  33. 

569.  A.  G.,  Operation  de  la  eataracte  sur  uu  oeil.  sans  attendre  que  I'autre 

cell  soit  affecte.    Ann.  d'Oc.  XIV,  p.  34. 

570.  Rub.  Ogez.,  Cataract  monocle  avec  strabisme  interne  de  I'oeil;  oper- 

ations heureuses;  guerison.    Ann.  d'Oc,  XIV,  p.  134. 

571.  .  Cataracte  congenitale  de  Toeil  droit  chez  une  femme  de  41 

ans  ayant  perdu  I'oeil  gauche  depuis  uu  an;  operation  suivie  de 
succes.     Ann.  d'Oc,  XIV,  p.  226. 

572.  Serre,  Operation  de  la  cataracte  selou  la  methode  par  deplacement, 

faite  avec  succes  apres  60  ans  de  cecite.    Ann.  d'Oc,  XIV,  p.  224. 

573.  Dubois.  Oper.  de  la  cataracte  datant.  de  44  ans.  suivie  de  retabllsse- 

ment  de  la  vue.    Ann.  d'Oc.  XIV,  p.  229. 

574.  Tavignot,  Notes  sur  les  cataractes  anciennes.     Gaz.  Med.  de  Paris. 
1846.    575.  Andreae.  Grundriss  der  gesammten  Heilkunde.     Leipzig.     Theil.  I, 

p.  99-118.    Cataract  literatur. 

576.  Watson,  Historical  et  critical  remarks  on  tlio  operation  fur  tlie  cure 

of  cataract.     Edinburg. 

577.  Gosselin,  Recherches  sur  I'abaissement  de  bi  eataracte.   Arcli.  Gener. 

de  Med.  .Tanv.  et  Fevr. 

578.  Sichel,  Essai  preliminaire  de  statistique  des  resultats  d'operation  de 

cataracte.     Ann.  d'Oc,  XVI.  p.  50. 


442 

184(i.     .-.T'J.    Wnltli.r.  CjiIiirMclolo;:!!-.  W  W.illlicr-s  u.  v.  Aiiiiiioii-s  .louni..  A'.  H.  2. 

r>8M.   FronmuUer.  AViedtM-erzouKUHJ?  lUn-  Krystnlliiisi'.    Ibid.,  VI,  H.  2. 

r>81.  Bartes,  D(»  la  eataracte.     Ia\  Clinique  de  Montpellier.    Fevr.  et  Aout. 

riS2.  Soidl  mid  Kanka.  Bericlit  uber  die  AViener  Augenklinik  und  die  ruit 

ilir    verbiindeue    Abtheilunj;:    des    AII.2;.    Krankenhouses.     Oestr. 

Jahrb.,   1840. 

583.  France,  J.,  Cas  dossiticalion  el  de  deplacenieut  de  la  leutille  cristal- 

line.    Gaz.  Med.  de  Paris,  No.  4.  184G,  et  Ann.  d'Oc,  XV,  p.  38. 

584.  Miguel,  Cristallin  passe  dans  la  cli.-uubre  anterieure  depuis  un  an. 

Emploi  de  la  pomade  df  (Jondret.  Resorption.  Bulletin  Gener. 
et  Therapeutique.     Ann.  d'Oc.  XIV.  p.>125. 

585.  Sichel,  De  quelques  accidents  consecutifs  a    'extraction  de  la  eata- 

racte et  en  particulier  de  la  fonte  puruleute  de  la  cornee  et  du 
globe  oculaire:  des  moyens  de  prevenir  ces  accideilts.  Bull.  Gener. 
de  Therap.   Ann.  d'Oc.  XV,  p.  128,  ISO-;  X-X,  p.  112. 

586.  Guerneiro,   Compte  rendu  de  la   clin.  opthal.  de  M.  Ansiaux,  pour 

I'annee,  1845.     Ann.  d'Oc,  XIV,  p.  145. 

587.  Gerster.    Reascension    d'une   eataracte    depriniee.      Medic.    Corresp. 

B.  1.    Bayrischer  Aerzte.    Ann.  d'Oc,  XVI.  p.  91. 

588.  Sichel,  Double  extraction  de  eataracte.  suivie  de  non  succes  complet; 

phthisic  de  I'oeil  droit  et  atrophic  connuencente  de  I'oeil  avec 
obliteration  de  la  pupille.  Iridodialysis  pratique  a  trois  reprises, 
chaque  fois  avec  succes  immediate  sous  le  i-apport  de  la  ma- 
noeuvre, non-retablissement  de  la  vision.  Atrophic  complete  de 
I'oeil  un  a  deux  and  apres  roporation.  Ann.  d'Oc,  XA'I,  p.  388. 
1847.     581).  Strieker.  Staar  oder  Starr.    A'.  Walther's  u.  v.  Amnion's  Journ.,  t.  A'l. 

590.  Guepin  (de  Nantes).  Notes  sur  les  resultats  comparatifs  de  I'abalsse- 

ment  et  de  I'extraction  dans  I'operation  de  la  eataracte.  Ann. 
d'Oc,   XVII,   p.   39. 

591.  Laugier.  Nouvelle  methode  d'operer  de  la  c.-itaracte  on  methode  par 

aspiration.     Ibid.,  p.  29. 

592.  Armati.  De  I'operation  de  hi  eataracte  par  aspiration.   Revendication 

de  priorite  en  faveur  de  M.  le  prof.  Pecchioni  de  Sienne.  Ibid., 
p.  79. 

593.  Cunier.  Nore  pour  servir  ;i   I'liistoric  de  la   succion  de  la  eataracte. 

Ibid.,  p.  85. 

594.  Sichel.  Recherches  histoi'i(iucs  sur  ri.pt'nilioii  par  succion  ou  aspi 

ration.     Ibid.,  p.  104. 

595.  Magne,  Note  sur  un  couteau-aiguille.  uouvfl  instninicnt  pour  I'oper- 

ati(m  de  la  eataracte.     Ibid.,  p.  111. 
59(i.  Behn  et  Auimon.  Zur  path,  anatomie  des  piol.ipsus  leutis  traum.  und 

hydroiis  tunic-ie  Jaeobi.     \.  AValtlier's  u.  v.  .Viiiiuoirs  .lourn..  A'll. 

H.  2. 
597.  Lagoguey.   l>u  IriiilciiuMil   i\v  cnlnnicles  hiileiises  par  succion.    Gaz. 

Med.  d.'   I'aris.   .No.  47. 


443 
1847.     r>OX.    Pri(li:ii<l.  Pc  l:i  (at.inKtc  ih-s  IfUiics  ;:ciisi.    I'rov.  .Touni..  No.  20. 

51^K>.  Kuhrlcn.   HeimTkuiifron  iilx-r  die  (•.itanicla  <iipsnlaris  sec.   iiacli  re- 

clination  dcs  linsonstaaics.     Wurtciiil).  roircsi...  B.  1.  Xo.  19. 
600.  llannoviT.  Qiichiues  <»l»sei-vatiniis  s\ir  la  sinictuif  dvi  .lisiallin  des 

des  mainiuifVres  et  le  rhoiniiif.     .\iiii.  d'Oc.  X\1I.  p.  '.tT. 
f;(»1.  llfylcn.  Cataracte  lenticulaiiv  choz  uno  feniuK!  de  74  aiis.     pruvoca- 
tioii  do  salivation  dans  \o  hut  d«'  pn^vcnir  les  accidents  inflam- 
matoircs.    Operation  \):\y  Mltaiss.-nicnt.     Kenssite.    Reflexions.  Ann. 

d'Oc.  XVI r.  p.  n.-.. 

602.  Rivand-I.andran.    Compte    rendn    <le    sa    clini<ine    a    Lyon    pendant 

I'aunee,  1S46.     Ann.  d'Oe..  XVIII.  i»p.  :{.  12. 

603.  Magne.  l>e  la  valeur.  de  roperation  de  la  .-ataraote  par  aspiration. 

Ann.  d"()e..  XVIII,  p.  38. 

604.  Blancliet.  Operation  de  la  cataracte  par  su(<ion.     Ibid.,  p.  3S. 

605.  Bonisson.  Remarqnes  sur  riHsuflisance  de  I'hunieur  aqueuse  qui  se 

nianifeste  a  la  suite  de  I'operation  de  la  cataracte  et  dans  quel- 
ques  autres  cas.     Ann.  d'Oc.  XA'II.  pi).  <!1.  108. 

606.  Sichel,  De  la  delocation  et  ile  raliaissciiimi  spontaues  du  cristallin. 

Oppenheim's  Zeitsohr..  f.  d.  des.  MeaU-in.  l.S4f>.  Ann.  d'Oc,  XVIII, 
p.  127. 

607.  Heylen.  Xouvelles  observations  tendant  a  prouver  retticacite  de  la 

salivation  niercnrielle.  corume  moyen  de  prevenir  rinflanimation 
consecutive  a  I'oix'ration  de  la  cataracte.  Ann.  d'Oc.  XVIII, 
p.  244. 

608.  :Magne.  Cataracte  capsulaire  ossifiee.  passee  dans  la  chainbre  ante- 

rieure:  extraction.    Ann.  d'Oc,  XVIII.  p.  271. 

609.  Velpeau,  Emploi  de  la  belladonne  apres  lOperation  de  la  cataracte. 

Ann.  d'Oc,  XVIII,  p.  270. 

610.  Brett,  On  cataract,  artificial  pupil  and  strabismus.     London. 

611.  Malfatti.  Xeue  Heilversuche.  I.    Gelungene  Vertilgung  des  grauen 

Staars  duicli  eine  aussere  Ileilmethode.    Wien. 
1848.    612.  Ran.  T'el»er  die  Beliundlung  des  .irrauen  Staars  durcli  Pliarm.  Mittel. 
V.  Waltlier's  n.   \'.  Amnion's  .Tonrn..  1.  VIII.  H.  3. 

613.  Xeil,  On  tlie  cure  of  cataract,  witli  a  prjulical  suniniary  of  tlie  best 

modes  of  operating.     Liverpool. 

614.  Rivaud-Landrau,  De  la  kystotoniie  posterieure.  on  decliirement  de  la 

cristalloide  post,  apres  I'operation  de  la  cataracte  par  extraction, 

conime  moyen    d'eviter  la  formation  des    cataractes    (•a!)sulaires 
consecutives.    Ann.  d'Oc.  XIX.  p.  7A. 
61.5.  Marcus,  Ueber  die  Naclibehandhui-  b.M  Staan.perationen.     Casper's 

Wochenschrift.  No.  49. 
6ir,.  Sichel.  Des  principes  rationels  et  des  limites  de  la  curabilites  des 

cataractes  sans  operation.     Bullet,  de  Therap.  et  Ann.  d'Oc,  XX, 

p.  76. 


444 

1848.    617.  Ceroid,  Elementa  pliotoinetri  ad  curam  cataraetao  seciind.  adhibendi, 
etc.     Madgeburg. 
G18.  Malgaigne,  Des  divers  espeees  de  cataracte.    Ann.  d'Oc,  XXI.  p.  234. 
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622.  Ran,  W.,  Ueber  die  Behundlung  des  graueu  Staars  durch  Pharm. 

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623.  Guepin,  Notes  sur  des  operations  de  cataracte  snivies  de  phenomenes 

remarquables.     Ann.  d'Oc,  XIX,  p.  116. 

624.  Tletzins,  Du  galvanisme  comme  moyeu  du  traitement  de  la  cataracte. 

Ann.  d'Oc,  XIX.  p.  123. 

625.  Langier,  Nouvel  essai  de  I'operation  de  la  cataracte  par  aspiration 

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626.  Boyer,  Entrainement  des  parties  anterieures  du  corps  vitre,  pendant 

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627.  Sichel,  Des  principes  rationels  et  des  limites  de  la  curabilite  des  cata- 

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628.  ,  De  la  .sortie  du  corps  vitre  pendant  ou  apres  I'operation  de  la 

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631.  Bowman.  Lectures  on  the  parts  concerned  in  the  operations  on  the 

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632.  Buzzi.  Aiguille  pour  la  cataracte  laiteuse.     Bolletione  delle  Scienze 

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633.  Boyer,  Lucien,  Deux  operations  de  cataracte  executees  par  un  nou- 

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634.  Langenbeck,  Max.  Klinische  Beitrage  aus  dem  Gebiete  der  Chirurgie 

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635.  WerdmuUer.  Einige  kurze  Bemerkungon  \iber  die  Natur.  und  Entste- 

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640.  Duval,  Coup  d'oeil  sur  la  iiiemoii-o  inibliee  par  Liiclou  Boyor  sous 

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XXII,  p.  75. 

641.  Boj-er,  I^ttre  eu  response  aux  obsorvations  criticiuos  qui  prooedent. 

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642.  Sauveux-,   Statistique  d»'S  sourds-muets  et  des  aveuglos  de  la  Bel- 

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643.  Tavignot.   De  I'hydropsia  de  la  capsule  du  cristallin.     Ann.   d'Oc, 

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1850.  644.  Nelatou,  I'arallelle  des  divers  uiodos  operatoiros  dans  lo  traitement 

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645.  I'ilz.    Zur    I'.ithologie    des    Krystallius(>nsystenis   des    mouschllchen 

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646.  Brodliurst,  On  the  cristalline  lens  and  cataract.     I.ondou. 

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658.  Junjrkeu.  Ueber  Staaroperationcii.     Dciitsclif  Klinik.  No.  S.  1850,  u. 

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659.  Beauclair.  Recherches  et  cxperioiK-eis  sur  la  eataraete  uoire  et  sur 

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660.  Petrequin.   Recherche  sur  la    eataraete  noir  et   sur  son   diagnostic 

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662.  Prichard,  Absence  eongenitale  du  cristallin.  Ann.  dOc.  XXIII.  p.  74. 

663.  Rivaud-Landrau,  De  la  luxation  et  du  deplacement  du  cristallin  par 

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664.  Barrier,    (iuelques   faits   intercessants   de  clinique   opthalniologique 

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666.  Hassner,   d'A..   Ueber  aetiologie  der  cataract.     Prager  Vierteljahr- 

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668.  Gerhard.  Peut-on  preveuir  la  foi-mation  d'une  eataraete  secondaire 

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669.  Coursserant.  De  la  pre-eminence  de  I'extraction  sur  I'abaissement  de 

la  eataraete.  Avantage  de  la  keratotomie  snperieure.  Ibid.  XXVI. 
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670.  Ammon.  v..  Optlialm.  Skizzen.  Verdunkelung  ues  Orbiculus  capsulo- 

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671.  Lebert,   Anatomic  pathologi(iue  et   curabilite  de  la   eataraete.    Un. 

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674.  Jaeger.  K..  Neuer  Optlialmostat.     Wien.  Zeitschr..  No.  6. 

675.  Jacob.  De  la  cat^u-acte.    Dubl.  Med.  Press..  Juill  et  Aout. 

676.  Rivaud-Landrau.  Cataracte  pierreuse  luxee  dans  la  chambre  ante- 

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677.  White.   Cooper.   Cataract  operation   an   ciiiein    Haren.    Med.   Times. 

1850,  u.  Ann.  d'Oc.  XXV.  p.  86. 

678.  TJllmann,  Aeusserst  spat  eingetretene  Autsaugung  der  Theille  einer 

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679.  Ansiarix.    Cliniciue   du   dispeusain*   opthalmique   de   Liege,    pendant 

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447 
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685.  Fnrnari,  Nouvelle  invention  d'nu  instrument  pour  I'operation  do  la 

cataracte  et  la  pupille  artitielelle.     Ibid,  p.  144. 

686.  Stellwag,  von  Carion.  Statistisc-he  Beitrage  zur  Lelire  vom  Staar  u. 

s.  w.   Zeitschr.  d.  Wiener.     April.  Mai,  .luni. 

687.  Blot.  Anat.  pathol.  de  la  cataracte  noire.     (Jaz.  Med.  Padis.  No.  2r,. 

u.  Ann.  d'Oc.,  XXXV,  p.  188. 

688.  Davaine.  Exanien  microscop.  de  deux  cataractes  lenticulaires.    Gaz. 

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689.  Aminon.  v.,  Zur  genesis  der  catar.  centr.  pyramid,  naeh  st^otions  re- 

sultaten.     Deutsche  Klinik.  No.  9. 

690.  Laugier.  Nouvelle  Aiguille  a  lance  mobile  pour  I'abaissement  de  la 

cataracte.  Keratotome  cache  termine  par  une  lance  mobile  ar- 
ticulee  pour  Textraction  <le  la  cataracte.  Ann.  d'Oc.  XXVIII, 
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691.  Wilde.  Cataracta  :Morgagni.     Med.  Times  and  Gaz..  October. 

692.  White,  Cooper,  Cataractes  congenitales.     Ann.  d'Oc,  XXXV,  p.  187. 

693.  Oppolzer.  Cataract  als  complication  des  diabetes  mell.   Heller's  Jour. 

f.  Psych,  u.  Path.  Chemie.,  No.  11  u.  12. 

694.  Chadwick,  Luxation  du  cristallin  sons  la  conjonctive.    Lancet,  Avril. 

695.  Comperat.    Luxation    spontanee    du    cristallin    transparent    dans   la 

chambre  anterieiu-e.  Extraction,  guerison.  T'n.  Med..  No.  71.  u. 
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696.  Larrey,  H.,  Luxation  du  cristallin  transparent.     <iaz.  Mod.  Paris,  u. 

Ann.  d'Oc.   December.   1851. 

697.  Kanka,  I^ntersuchnngcMi  ul)er  den  granen  Staar.     Ungar.   Zeitschr.. 

No.  34. 

698.  Thompson.   IL,   Cataracte  1rauniati(|ne.   Guerison   spontanee.     Dubl. 

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699.  Bowman.  De  I'emploi  des  deux  aiguilles  a  la  fois  dans  les  operations 

qui  se  pratiquent  sur  I'oeil.  et  specialoment  dans  la  cataracte  cap- 
sulaire  et  la  formation  d'une  pupille  artiticielle.  INIed.  Times  and 
Gaz.:  Ann.  d'Oc.  XXIX.  p.  293.    1853. 

700.  Appia,  Notice  sur  soixante  huit  operations  de  cataracte.    Ann.  d'Oc. 

XXX,  p.  105;  Schweiz.  Zeitschr..  f.  Med.  Chin,u-g.  u.  (Jeburtshulfe, 
18.52.  H.  .505. 


448 

1852.  701.  White.  Cooper,  Ueber  angeborene  cataract.     Med.  Times  and  Gaz. 

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702.  Deval,  Cli.,  Cousecutive  ainaurose  uacli  der  Staaroperatiou.    Bullet. 

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703.  Gerdy,  Neue  nadel  zur  dopressiou  der  cataract.     Gaz.  des  Hop.,  91, 

u.  Un..  9.3. 

704.  Amnion,  v..  Extravasation  sanguine  dens  la  capsule  cristalline.   Note 

pour  servir  a  I'histoire  de  riiemopthalmie  interne  et  surtout  des 
vaisseaux  de  nouvelle  formation  dans  les  extravasations  san- 
guines.    Ann.  d'Oc,  XXVII.  p.  39. 

705.  Jobert,  Operation  de  la  cataracte.     Traitement  preparatoire.     Ann. 

d'Oc,  XXVII,  p.  65. 

706.  Chassaignac,  Nouveau  precede  pour  niaintenir  la  glace  en  contact 

avec  I'oeil,  comme  moyen  de  prevenir  on  de  combattre  les  inflam- 
mations oculaires  particulierement  a  la  suite  des  operations  de  la 
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707.  Wedl,  De  la  stase  sanguine  qui  se  montre  dans  les  vaisseaux  ciliares, 

immediatement  apres  la  sortie  de  I'humeur  aqueuse.  Zeitselir. 
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708.  Deville,   Des  cataractes  congenitales.     Expose  de  la  pratique  des 

chirurgiens  anglais,  et  en  particulier  de  Mons.  W.  White  Cooper. 
Ann.  d'Oc,  XXVIII,  p.  86. 

709.  Courserant,  De  la  preminence  de  I'extraction  sur  I'abaissement  de  It 

cataracte.  Avantages  de  la  keratotomie  superieure.  Ann.  d'Oc, 
XXVIII,    p.    107. 

710.  Charriere.  Aiguille-pince  pour  I'operation  de  la  cataracte.     Reclama- 

tion Ibid,  p.  '207. 

711.  Tavignot,   Faut-il  employer  les  collyres  irritants  dans  les  conjonc- 

tives  cdnsecutives  a  I'operation  de  la  cataracte.  Ann.  d'Oc, 
XXVIII,  p.  208. 

712.  Dnbreuil.  Contusion  de  I'oeil  gauche.     Ilemopthalmie  sous-conjonc- 

tivale.     Luxation  du  cristallin.     Ann.  d'Oc,  XXVIII.  p.  211. 

713.  Gerdy,  De  I'emploi  d'une  niuivelle  espece  d'aiguille  dans  I'abaisse- 

ment de  la  cataracte.    Ann.  d'Oc,  XXVIII,  p.  214. 

714.  Deval,  Amaurose  consecutive  a  I'operation  de  la  cataracte.     Ann. 

d'Oc,  XXVIII,  p.  223. 

715.  Sichel,  Ueber  eine  Rohrenpiucette  zur  extraction  der  l^apselcataract 

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1853.  716.  Bechler.  De  dislocatioue  lentis  cristallinae.     Lips. 

717.  ( Juepin.  de  Nantes,  Des  cataractes  de  naissance  el  des  operations  qui 

leur  conviennent.     Ann.  d'Oc,  XXX.  p.  75. 

718.  Richard,  A.,  Des  divers  especes  de  cataracte  et  leur  indications  ther- 

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449 
1853.    719.  Dinge,  StJitistitiuc  des  resultats  <le  Topoi-auon  de  la  cataracte  pra- 
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720.  Dixon.  Observations  de  catariietes  lionidcs  dv  .M<.rj;a;:ni.     Tlie  Lan- 

cet. No.  "J. 

721.  Bergheni.  Calaraetc  giierie  i)ar  un  trailenient  luedical.     Ann.  de  la 

Soeiete  Med.  d.  Anvers..  p.  2r„s.  u.  Ann.  d'Oc,  XXXV,  p.  189. 

722.  Lopez,  Trait enient  medicale  de  la  cataracte  par  Tiodure  de  potassium 

et  I'animoniaque  liquide.    El  Porvenir  Medico,  Nov.,  18G3,  u.  Ann. 
d'Oc.  XXXV,  p.  118. 

723.  Desmartis,  Cataracte  liquide  operee  par  aspiration,  description  d'un 

nouvel  aspirateur.     Revue  de  Tlierap.   dn   Midi.,   No.  0,   u.  Ann. 
d'Oc,  XXXV,  p.  190. 

724.  Jenni,  Intiaiumation  de  la  capsule  cristalloide.     Gaz.  des  Hop..  127; 

Ann.  d'Oc,  XXX,  p.  87. 
72.">.  Kirk.  Depots  osseux    dans    la  nieiubrane  vit reuse    et    le    cristallin. 

Montli.  Journ.,  Novembei-. 
72G.  AValtou.  Haynes.  Diagnostic  des  cataractes  commencantes  chez  les 

persounes  agees.    Med.  Times  and  Gaz.,  October. 

727.  Gros,  Du  cristallin  et  de  sa  capsule.     Ann.  d'Oc,  XXIX.  p.  22. 

728.  Chassaignac,  Catar.  corticalis.    Extraction,  AnAvendung  der  Kalte  u. 

des  Eises.  schnelle  Heilung.    Gaz.  des  Hop.,  109. 

729.  Canton,  Ossification  du  cristallin  et  de  la  capsule.     Lancet  u.  Ann. 

d'Oc,  XXIX,  p.  51. 

730.  FoUin,  Untersucliung  der  retina  uud  der  lirystallinse  mittelst  eines 

neuen  optischen  instrumentes.    Rapport  daruber  von  Chassaignac. 
Memoire  de  la  Soeiete  de  Chirurgie,  III,  4. 

731.  Jacob,  A.,  De  I'operatiou  de  la  cataracte  pratfque  a  I'aide  d'un  fine 

aiguille  a  coudre  introduite  a  travers  la  cornee.  Ann.  d'Oc.  XXIX. 
p.  172. 

732.  Laugier,  Nadel  zur  suction  der  cataract.    LTnion,  110,  u.  Ann.  d'Oc. 

XXXIV,  p.  36. 
73.3.  FoUiu.  Luxation  sous-conjonctivale  du  cristallin.     Arcli.  Gener.  de 
Medicine,  p.  210;  Ann.  d'Oc.  XXXIV.  p.  39. 

734.  Trexler,  Reascensiou  de  cataractes  operees  a  I'aiguille.     Ann.  d'Oc, 

XXX,  p.  100. 

735.  Guepin.  Connai.sons  nous  bien  les  fonctions  du  cristallin?  Ann.  d'Oc, 

XXIX,  p.  147. 

736.  Trettenbacher,    Statistique    de    I'hospital    optlialmique    de    Moscou, 

1850-53.    Ann.  d'  Oc,  XXX,  p.  129. 

737.  Quadri,  Intorno  all'  ernia  iride  consecutiva  all'  estrazione  anteriore 

del  cristallino. 

738.  Bosch.  De  I'opacite  de  la  capsule  cristalline.  Ann.  d'Oc.  XXX,  p.  225. 

739.  Alessie.  Opthalmostat  du  Prof.  Jaeger  modifie.     Ann.  d'Oc.  XXX, 

p.  229.     Nouveau  kystitome.    Ibid.  p.  230. 


450 

1853.  T-K).   H.Tvicz.  Uvww  (.ptlialniolojiicinc  du  s.Tvicf  de  ,M.   I'.-ticinin.    Cata- 

racte,  cataracte  noire.    Ann.  d'Oc,  XXX.  p.  24;». 

741.  Burdach.   Ueber  die  Verfettuns  vou  proteinlialtiji-eu  snbstanzen  in 

der  peritonealhohle   lebendtT  Thiore.     Aircli.   Aixh..    YI,   p.   103. 
(Dorthin  f-ebrachte  linsen-verfettetcn.i 

742.  White,  Cooper.  Du  changemeut  de  la  vue  comme  signe  precurseur 

de  cataractes  dures.     Associat.  Medical  .Tourual.  November.  1853. 

743.  Kletzinsky,  Vergleicbung  der  /usanmieusetzung  der  krystallinse  unci 

getrockneter    eataracten.     Zeller's    Anli.    f.    riiysiol.   u.   Tathol. 
Chemie,   isr>3.   p.   '27>i;. 

1854.  744.  Bo\A-man.    Leeous    .sur    les    ])arties    iiiteicssces    dans    Ics    operations 

pu'on  pratique  sur  I'oeil.     Aim.  d'Oc.  XXXI.  p.  7. 
745.  I>ohmeyer,  Beitrage  zur  Histologie  nnd  Aetiulogle  der  erworbenen 

I.insenstaare.    Zeitschr.  f.  Rat.  Med..  Y.  II..  1  u.  2. 
740.  Bonders,  Entzundliche  cataract.     XNederl.    Lancet,  No.  t>. 

747.  Broca,  Memoire  sur  la  cataracte  capsulaire,  etc.     Arch.  d'Optb.  de 

Jamain,  H.,  p.  18-i. 

748.  Graefe.  A.  v.,  Ueber  Staaroperationen.     Deutsclie  Kliiiik..  Nos.  1,  2, 

4  u.  6;  Arch.  f.  Opthal.,  Bd.  I,  1,  p.  323-325. 
74Sa. ,  Cataract  niit  doppelteni  biconvexem  linsenkern.     A.  f.  O.,  I,  1, 

p.  323. 

74Sb. .Extraction  einer  liCi  .Jahrc  reifen  cataract.     Ibidem,  p.  326. 

74Sc.  ,  Cataract  aus  phosphorsauer  kalkerde  bestehend.    Ilndem.  p.  330. 

74,Sd.  .  Falle  von  cataracta  nigra,  mikroscopische  untersuehung  einer 

solchen.    Ibidem,  p.  333. 
74Se.  ,  Zwei  falle  von  linsenluxationen.    Ibidem,  p.  3.''.<!. 

749.  .Taeger.  E..  Ueber  staar  u.  Staaroperationen.    Wien,  in  8o. 

7.50.  Pamard,  De  I'operation  de  la  cataracte  chez  les  personnes  tres  avan- 
cees  en  age.    Ann.  d'Oc.  XXXI,  p.  224. 

751.  His,   Mikroscop.  Untersuehung  eines  weicheu  linsenstaars  bei  dia- 

betes.   Arch.  f.  Pathol.  Anat..  Y'l.  p.  .501. 

752.  Carton.  De  I'operation  de  la  cataracte  par  kerntotomie  superieure. 
"*'  These  de  Paris. 

75.3.  Critchett.  Cataracte  capsulaire  congenitale.     Diibl.  :Med.  Press. 

754.  Oettingen,  Observationes  (juaedam  de  cataractae  operatione  extrac- 

tionis  ope  instituenda.    Diss.  Inaug.  Dorpati. 

755.  Robin.   Ch.,   Opacite  de  la  <;ii»sulc   dii   crist.iUin   coiist.ilee   sous  le 

microscope.     Arch.  d"()pth;ilni..  II.  p.  101. 

7.56.  Alessi,  Luxation  du  cristallin.     Calaractc  caiisulo-lenticnlaire.    Ibid, 

p.  00. 

7.57.  Franchon.  Elude  sur  l.i  calaradc  noin-.     Il)id.  p.  101. 

7.58.  Cade.  A.,  Memoire  prati(inc  sin-  la  calarMctc.  suivi  (Vim  tableau  syn- 

oi)tique  des  operations  de  I'.mtenr.     Montpcllier.  in  So. 

7.59.  Taire,   Quehpies  considerations   sm-  lopcr.ition   (h'  la    c-it.iracte  par 

extraction.     Ibid.  i».  111. 


451 

1854.  700.  Ana.uiKistiikis.   Essjii   siir  rdpcrntioii  dc  l.-i    ictiin'  ct  des  milieux  de 

I'otnl  siir  1(*  vivant,  au  moyeu  d'lm  uouvcl  i.i)tli;ilmoscor)e  (crls- 
tallin).     Aun.  d'Oc,  XXXI,  p.  110. 

701.  Coruaz,   Recherches  statistiques  sur  la  frequencL'  (.-omparatlve  des 

conleiirs  de  I'lrls.     Ann.  d'Oc,  XXXI,  p.  250  nnd  276. 

702.  Jacob.  Description  du  crista Uin  et  de  sa  capsule.  Ann.  d'Oc,  XXXII, 

p.  24;  Encyclopedie  Anatomique. 

703.  Game,  Cataracte  congenitale  operee  avec  succes  sur  uu  homme  de 

55  ans.    Moniteur  des  Hopitaux.    Juin. 

704.  Walton,  Haynes,  Degenerescence  cretacee  du  cristallin  et  de  sa  cap- 

sule, dans  des  yeux  qui  ont  subi  une  desorganization,  comme 
cause  de  douleur  et  d'irritation  et  d'alterations  morbides  de  I'oeil 
sain,  qui  imitent  I'asthenopio  et  menacent  de  cecite.  Med.  Times 
and  Gaz.,  p.  154.  1854. 
765.  Saez,  Effect  facheux  d'uu  air  humide  et  froid  sur  les  operes  de  cata- 
racte. La  Cronic  de  los  llospitales,  8  Mai,  1854.  Ann.  d'Oc, 
XXXV,  p.  190. 

1855.  760.  Doumit,   De  I'oporatio   de   la    cataract  par  keratotoniie   superieure, 

accidents   qui   peuvent   se   presenter,    statistiq\ie   raisonnee,   etc. 
Ann.  d'Oc,  XXXV,  p.  164. 

767.  Heyman.  Classification  des  cataractes.     Schmidt,  Jahrb.,   LXXXV, 

p.  116. 

768.  Magne.  ^Memoire  sur  les  hereux  efifets  de  la  glace  appliquee  imme- 

diatement  apres  Toporation  de  I'abaissement.    Gaz.  Med.  de  Paris, 
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769.  Rau,  Cataracta  nigra  u.  angeboreue  cataracte.     Arch.  f.  Opth..  Bd. 

1,  A.  2,  p.  167-205. 
775.  ,  Sectionsbefund  nach  vorausgegangeuer  reclination.  Ibid,  p.273. 

770.  Graefe,  A.  v.,  TJeber  die  linoare  extraction  der  linsenstaare.     Ibid, 

p.  291. 

771. ,   Abberratiou   der   Augenachse   bei  der   lixation   bedingt  durch 

Schiefstellung  der  linse.     Ibid,  p.  291    . 

772. ,  Eiu  aiissergewolinlicher  fall  von  extraction  einer  in  die  vordere 

Kammer  vorgefallenen  verkalkten  linse.    Ibid,  Bd.  IT,  A.  1,  p.  195. 

773.  ■ ,  Falle  von  spontaner  linsenluxation.     Ibid,  p.  250. 

774. .  Xotiz  von  Schichtstaar.     Ibid.  p.  273. 

770.  Arlt,  Die  ki-ystallinse  und  ihre  kapsel,  in:  Die  krankheiten  des  auges. 
Prag. 

777.  Ansiaux,  .T.,   Luxation  du  cristallin  sous  la   conjonctive.     Gaz.  des 

Hop..  No.  24. 

778.  ^lalgaigne.  Sur  le  siege  et  les  diverses  varietes  de  cataracte.    Rev. 

Med.  Chir.,  .Tanv.  et  Fevi-. 

779.  Sichel,  Memoire  sur  la  cataracte  noire.    Arch.  d'Opth.,  t.  IV.  p.  31. 

780.  Faber.  Die  behandlung  der  cataracte  secundaria  zu  Paris.     Deutsche 

Klinik,  No.  .51. 


452 

1855.  781.  Haj'es.  .7.,  Aiguille    trancliaute    pour    roperation    de    la    cataracte. 

American  Journ.    Juillet. 
782.  Richard,  Ad.  et  Robin,  Ch.,  Do  la  nature  des  cataractes  capsulaires. 

Gaz.  Hebd.,  No.  38. 
78.S.  Critchett,  Operation  de  cataracte  adhereute  chez  un  adulte.     Med. 

Chirur.  Transact,  XXXVIII. 

784.  France,   Luxation   du   cristallin   .sous   la  conjonctive.     Guy's   Hosp. 

Rep.,  3,  Ser.  1. 

785.  Walton,  H.,  Cataracte  noire.    Assoc.  Journ.    December. 

786.  ,  Luxation  spontanee  du  cristallin.     Med.  Times  and  Gaz.    Dec. 

787.  Ritterich,  Zur  Staaroperation.     Deutsche  Klinik,  No.  50. 

788.  Testelin,  Note  sur  quelques  points  de  la  structure  du  cristallin  et  de 

sa  capsule,  a  Tetat  normal  et  a  I'etat  pathologique.     Ann.  d'Oc, 
t.  XXXIV,  p.  109,  et  t.  XXXV,  p.  61. 

789.  Taylor,  Corps  amylaces  dans  le  cristallin.    The  Lancet.  1855,  p.  242. 

790.  Critchett,  Cataracte  capsulaire  congenitale.    Ann.  d'Oc,  XXIII,  p.  94. 

791.  Doumit,  De  I'operation  de  la  cataracte  par  keratotomie  superieure. 

Paris.    These. 

792.  Warlomont,  Quelques    mots  sur    la  pratique  opthalmologique    des 

chirurgiens  de  Londres.     (De  I'extraction  de  la  cataracte.)    Ann. 
d'Oc,  XXXIV,  p.  7. 

793.  Quadri,  Cataracte  traumatique  guerie  par  I'application  de  la  belle- 

done.    Ann.  d'Oc,  XXXIV,  p.  19. 

794.  Sichel,     Iconographie     opthalmologique     (cataracte).      Ann.     d'Oc, 

XXXIV,  p.  53. 

795.  Nelaton,   Operation  de  cataracte,   entropion,   serre  fine.     Journ.  de 

Med.  et  de  Chir.  Prat.,  1854,  p.  113  u.  Ann.  d'Oc,  XXXV,  p.  176. 

796.  Deval,  De  la  luxation  sous-conjunctivale  du  cristallin.    Bull.  Gener. 

de  Therap.,  XLVI,  p.  451,  u.  Ann.  d'Oc,  XXXV,  p.  157. 

797.  Letenueur,  Guerison  spontanee  d'une  cataracte  traumatique.  Compte 

rendu  de  la  Societe  Med.  de  la  Loire-Inferieure,  1855,   u.  Ann. 
d'Oc,  XLIII,  p.  50. 

798.  Salomon,   Degenei'escence  graisseuse  du  cristallin,  cas  dans  lequel 

de  uomun   cristallin.     Assoc.   Med.   Journ.,   1855.   u.   Ann.   d'Oc, 
XLIII,  p.  127. 

1856.  799.  MuUer,  E.,  Cataracia  nigra.     Arch.  f.  Opth.,  Bd.  II,  A.  2,  p.  164. 

800.  ,  Schichtstaar.    Ibid,  p.  166. 

801.  Robin,  Anatomie    pathologique    des    cataractes    en  general.    Arch. 

d'Opth.,  t.  V. 

802.  Spielmann,  Do  la  cataracte.    These  de  Strasbourg. 

803.  Huge,  De  la  cataracte  secondaire  et  son  extraction  par  la  sclerotique. 

These  de  Strasbourg. 

804.  Joseph,  Bemerkungen    uber    krankhafte  Vorgange    an    den  Augen 

Cholerakranker.     Gunsb.  Zeitschr.  f.  Klin.  Med.,  t.  A'^II. 


453 

U^M-    ;i 

n    st;i;ii 

oiierirt  isi, 

p.  177 

illinsp. 

Zcilsc-I 

1I-.  (1.  Gespll- 

185«J.    8()r».   Crai'fe.  A.   v..   Wic   KimiiU.'.   (h'lvn  ciiifs 

sehon.  etc     Arch.  f.  Optli..  Bd.  1'.  A.  1 
80G.  Wedl.  rutcrsiK-liunu'  ciiicr  wtnihlen  krys 

s<-haft  d.  Wieu.  AoiJito.  No.  47. 
807.  Critfhett.  I)»>  la  facilite  d<'  roxtr.i.tioii  dr  la  cataractf  dans  certains 

(•as  de  pupillo  artitieielle.  Lancot.  25  Juin,  et  Gaz.  des  Hop.,  No.115. 
SOS.  Desmari-es  et  Kobin.  Ch..  Stnieture  de  la  cataracte  ponotuee.     Gaz. 

des  Hop.,  No.  64. 
800.  Desniarres.  Extracti(»n  liiieairc  dune  eataraete  traumaticiue  chez  nn 

enfant.    Guerison  en  24  lieures.     Ibid,  No.  70. 

810.  Salomon.  Vose,   Extraction    des  cataractes    traumatiques    recentes 

comme  moyen  de  diagnostic.    Assoc.  Journ.,  Avril. 

811.  — r-,  D'un  signe  caracteristique  des  cataractes  dures.    Ibid.   Juln. 

812.  Stellwag.   v.   Carion.   Ein  fall  von  ectopia  der  normwidrig  kleinen 

krystallinse.     Wien.  Wochenbl.,  No.  49  et  50. 

813.  Pernzzi,  Cataracte  capsnlaire  gnerie  par  un  traitemeut  inercuriel. 

Raccogl.  di  Fano  u.  Ann.  d'Oc,  XLIII,  p.  53. 

814.  Tavigot,   Nouvelle  methode  operation  de  la  cataracte  par  debride- 

ment.   Academic  des  Sciences.  19  Mai,  1856. 
1857.    815.  Prichard,  Anatomic,  physiologic  et  maladies  de  la  membrane  pupil- 
laire.     Etiologie  de  la  cataracte  capsulaire  r-entrale.   Iraduit  de 
I'anglais  par  M.  Doumic.     Union  Med.,  No.  126  et  128. 

816.  MuUer,  H..  Ueber  die  anatomischen  verlialtnisse  des  kapsolstaare. 

Arch.  f.  Opth..  Bd.  Ill,  A.  1.  p.  55. 

817.  .  Ueber  den  Sitz  des  Kapselstaars  und  Mittheilung  neuer  Falle. 

Yerhandl.  d.  Phys.  Med.  Gesellsch.  zu  Wiirzb.,  t.  VIII. 

818. .  Untersuchiingen  uber  die  Glashaute  des  Auges,   insbesondere 

die  Glaslamelle  der  Choroidea  und  ihre  senilen  veranderungen. 
A.  f.  O.,  II,  2,  p.  1  und  loco,  p.  2.31. 

818a.  Forster.  Zur  pathologischen  anatomic  der  cataract.     A.  f.  O.,  Ill, 
2.  p.  187. 

819.  .Tordan.  F..  Fiirneaux.  Rapports  de  la  cataracte  avec  les  maladies 

du  coeur.     Brit.  Rev.,  Avril. 
819a.  Graefe,  Ueber  verkleinerung  des  linsensystems  mit  erlialtung  der 

transparenz.     A.  f.  O..  Ill,  2,  p.  576. 
819b.  .  Notiz  liber  entstelning  des  schichtstaars  an  dislocirten  linsen. 

Ibidem,  p.  372. 
819c.  .  Beobachtung  einer  partiellen  dislocation  der  linse  unter  die 

con.innctiva  durch  ein  trauma.     Ibidem,  p.  365. 

820.  Nelaton.  Cataracte  double  (tremulante).    Un.  Med.,  No.  78. 

821.  Taylor.  R..  De  la  catai-acte  suivi  de  remarques  sur  ranatomie  et  la 

physiologic  du  cristallin.     Med.  Times  and  Gaz.     Mai. 

822.  Williams.  De  la  cataracte  zonulaire.    Americ.  Med.  Chir.  Rev.    Sept. 

823.  Castorani.  De  I'etiologie  de  la  cataracte.     Gaz.  des  Hop.,  No,  82  et 

Gaz.  Ilebdom..  No.  .36. 


454 

1857.  824.  Desmnrn's.    Operation    dcs    cataractt's    capsulo-leiiticulaires    adher- 

entes.     Gaz.  ties  Hop.,  No.  106. 

825.  Valez.  l)es  eataractes  artificielles.    .Touru.  tie  Brux.,  Juin. 

826.  Kuntie,  Ueber  kunstliche  cataract.    Zeitsclirift  fur  Wissenscli.  Zoolo- 

gie,  YIII,  p.  466. 

827.  Streitfeiltl,  Statistics  of  cataract.    K.  I>.  O.  II.  Optlialm.  Hosp.  Rep.  I. 

828.  BatJer.     Ibiti,  p.  43,  142. 

829.  Dixon,  Abnormal  position  of  tlie  crystalline  lens  occurring  In  four 

members  of  the  same  family.     Opth.  Hosp.  Rep.,  I. 

830.  Streatfeild,  Six  cases  of  cataract  in  one  family.     O.  H.  R.  I.,  p.  104. 

831.  Martin,  On  the  operations  for  cataract  among  the  natives  of  India. 

O.  H.  R.  I.,  p.  161. 

832.  Hulke,  Observations  on  the  growth  of  the  crystalline  lens,  and  on 

the  formation  of  capsular  opacities.    O.  H.  R.  I.,  p.  182. 

833.  Valenciennes  et  Fremy,  Recherches  sur  la  nature  du  eristallin  dans 

la  serie  animale.     Bull,  de  I'Acad.  des  Sciences.    Juin,  1857. 

1858.  834.  Cooper,  White.  Des  luxations  du  eristallin.     Med.  Times  and  Gaz.,  2 

Janv. 

835.  Sichel  et  Robin,  De  la  cataracte  noire.    Gaz.  Med.  de  Paris,  No.  51. 

836.  Fenner.  C.  S.,  De  la  cataracte.    Amer.  Med.  Chir.  Rev.   Janv. 

836a.  Graefe,  Ueber  die  iridectomie  bei  spaterer  verschiebung  der  krystal- 

linse.     A.  f.  O.,  IV,  2,  p.  211. 
836b.  ,  Ueber  die  mit  diabetes  mellitus  vorkommenden  sehstorungen. 

Ibidem,  p.  230. 
836c.  ,  Verklebung  der  vordern  linsenkapsel  mit  membrane  desce- 

metii    und  bemerkungen    uber  gewisse    formen  von    nachstaar. 

Ibidem,  p.  241. 

837.  Koeberle,  de  la  cataracte  pyramidale.    Gaz.  de  Strasb.,  No.  5,  et  Ann. 

d'Oc.  XLIII,  p.  192. 

838.  Mahieux,  Luxation  spontanee  du  eristallin,  utilite  de  I'atropiue  pour 

le  reduire.    Monit.  des  Hop.,  Avril,  et  Bullet,  de  Therap.,  Juin. 

839.  Salomon.  Vose,  Gas  de  eataractes  unilaterales,  influence  de  I'opera- 

tion  sur  la  vision.    Brit.  Med.  Journ.,  April  17. 

840.  Geissler,  Zur  lehre  vom  grauen  staar.    Schmidt's  Jahrb.,  t.  C,  p.  249. 

841.  Kuhnhorn,  De  cataractae  aquae  inopia  effecta.    Gyrphiae.    1858. 

842.  Streatfeild,  Cataract  first  affects  the  right  eye  or  left  eye.    O.  H.  R.  I. 

p.  214. 

843.  Salomon,  Vose,  The  reclination  of  cataract  with  two  needles.    O.  H. 

R.,  I,  p.  218. 

1859.  844.  France,   The  cataract  in  association   with  diabetes.     Opth.   Hosp. 

Rep.,  I,  p.  272. 

845.  ,  On  the  use  of  forceps  in  extraction  of  cataract.    Ibid,  II,  p.  20. 

846.  Hulke,  Rupture  of  the  eyeball,  with  escape  of  the  lens,  etc.    Ibid,  I, 

p.  292. 


455 
1859.    847.  Arlt,  Ueber  cataraeta.    Spitalzeitung.  No.  1. 

848.  Cafife,  Traiteinent  inodical  de  la  cataracte.     (iaz.  des  Hop.,  No.  8. 

849.  GiU'pin,  Traitement  medical  de  la  cataracte.    Bull,  de  Therap.,  Fevr. 

850.  Laurence,  Z.,  Luxation  traumatique  du  eristallln.     Med.  Times  and 

Gaz.,  5  Mars. 

851.  Rolirer,   J.   S.,    Cataracte   eonticiiifalc;    opcfMlloii;    fi"»-'i'i«<>u-      Amer. 

IMed.  Chir.  Rev.,  Jan. 

852.  Robin,  Ch.,  De  I'anatomie  de  diverses  lorincs  de  cataracte.     Bull. 

de  I'Acad..  XXIV.  ]).  84.S.  u.  Ann.  d'Oc.  XLIII.  p.  10.';. 

853.  Weber,  C.  O..  Vorfall  der  linse  und  einhellung  eines  wimperhaares 

in  der  vordere  augenkammer.     Med.  Centr.  Zeit.,  No.  5. 

854.  Bonat'os-Lazermes,  De  la  catarncte.     .Tourn.  de  Toulouse.     Juill. 

855.  Van  Doninielen.  (Juerison  niedicale  de  la  cataracte.    Nederl.  Tljdsch., 

.luin. 
850.  Hildige.  J.  H.,  lleinorrli.ijiie  apres  I'operation  de  la  cataracte.     Lan- 
cet,  12  Sept. 

857.  Jager,  E.,  Fall  von  cataract.     Wien  Zeitsclir..  No.  ol. 

858.  Bayard.  Traitement  de  la  cataracte  par  la  galvanocaustique.     Gaz. 

des  Hop.,  No.  149. 

859.  Dechambre.  De  la  cataracte  diabetique.    Gaz.  Hebd.,  No.  51. 

860.  Desmarres,   Curec  avec  cystotome  pour  I'extraction  lineaire  de  la 

cataracte.     Gaz.  des  Hop.,  No.  121. 

861.  Joseph.   G..   Dislocation   eines  cataractoseu   linsensystems   in   folge 

V'  II     einwirkun2'    vo''     at    •pln-eintraufehmg.      Gunzb.    Zeitsobr., 
No.  5  u.  6. 

862.  Waldhauer,  Cataracta  centralis.     Rigaer  Beitr.  z.  Heilk..  IV,  p.  100. 

863.  Walton,  Cataracte;  position  abnormale  de  I'iris  et  du  eristallln.  dla- 

bete,  operation,  succes.    Med.  Times  and  Gaz.,  12  Nov. 

864.  Graefe,  v.,  Ueber  sehstorung  be!  diabetes.     Deutsche  Klinik.  1859, 

p.  104. 
865.Caussade,  Recherches  pour  servir  a  I'histoire  pathologique  de  la  cata- 
racte et  de  son  traitement.  These.    Montpellier. 

866.  Lowenhardt,  Procede  pour  I'extraction  de  la  cataracte.     Gaz.  Hebd.. 

No.  7,  u.  Ann.  d'Oc,  XLIV.  p.  53. 

867.  Chassaignac,  Resorption  de  I'iris  du  eristallln.     France  Medicale  u. 

Ann.  d'Oc.  XLIV,  p.  5.".. 

868.  Zepernik.  Meletemata  de  cataracta.     Diss.  Dorpat. 

1860.    869.  Gosselin,   Repos  absolu  des  paupieres  et  du  globe  de  I'oeil   apres 
I'operation  de  la  cataracte.    Gaz.  des  Hop.,  No.  165. 

870.  Weber,  C.  O..  Ueber  den  ban  des  glaskorpers  und  die  pathologischen, 

namentlicb   entzundlichen   verwundungen   desselben.     Virchow's 
Arch.,  XIX,  p.  367. 

871.  Leport.  Guide  pratique  pour  bien  executer,  bien  reussir  et  mener  a 

bonne  fin  I'operation  de  la  cataracte  par  extraction  superieure. 
Paris,  u.  Ann.  d'Oc.  XLIII,  p.  200. 


456 


872.  Viol.  Ziu-kersc'halt  (U's  grauon  staars  bei  diabetes.     yWd.  Centr.  Zig., 

No.  51. 
873.Wilson.  Disloeatiou  of  the  lens.     Opth.  Hosp..  No.  Ill,  p.  65. 

874.  Graefe,  A.  v.,  et  Schweiger,  Cataracta  traumatica  u.  clironische  cho- 
rioiditis durch  eineu  fromden  korper  iu  der  linse  bedingt.     Arch.  f.  Opth. 

Bd.  VI,  p.  134,  und  ectatische  chorioditis  mit  scleralstaphylom, 
linseudislocation  und  excavation  des  sclmerven.     Ibid,  p.  150. 

875.  MuUer,  H.,  Nachtrage  zuni  kapselstaar.     Verhandl.  d.  Win-zb.  Phys. 

Med.  Gesellsch..  t.  X. 

876.  Hesser,   Faserschichteustaar.    Zeitschr.   d.   Ges.  d.   Aerzte  z.   Wien, 

No.  23. 

877.  Mitchell,    De    la    cataracte   diabetique,    experiences    physiologiques. 

Gaz.  Hebd.,  No.  48. 

878.  .  On  the  production  of  cataract.    Amer.  Journ.  of  Med.  Science. 

879.  Just,    Eigenthumlicher   kapselstaar,    etc.,    und    hinterer    polarstaar. 

Oesterr.  Zeitschr.  f.  Prakt.  Heilk.,  No.  30. 

880.  Schuft,  Die  Ausloffelung  des  Staares.     Ein  neues  verfahren.    Berlin 

in  8o.  u.  Ann.  d"Oc.,  XLIV,  p.  151. 

881.  Sichel.  Extraction  de  la  cataracte.    Gaz.  des  Hop..  No.  20  et  32. 

882.  Graefe.  A.  v.,Ueber  die  vorsuge  eines  von  Dr.  Schuft,  erfundenen 

loffels  bei  der  linearextraction.    Arch.  f.  Opth.,  Bd.  VI,  A.  2,  p.  155. 

883.  Mitchell.    Cataract   bildung   durch    injection   von   zuckerlosung    ins 

subcutane  zellgewebe.  Oesterr.  Zeitschr.  fur  Prakt.  Heilk.,  No. 
39.  The  Amer.  Journ.  of  Med.  Sciences,  January,  1860.  Gaz. 
Hebdom.,  No.  48;  Ann.  d'Oc,  XLV,  p.  79. 

884.  Richardson,  Ueber  kunstliche  cataractbildung.     Oesterr.  Zeitschr.  f. 

Prakt,  Heilk.,  No.  45. 

885.  ,  Synthesis  de  la  cataracte.    Journ.  de  Physiol.,  Oct.,  p.  645. 

886.  Bouisson,  Histoire  d'un  aliene  aveugle  qui,  apres  avoir  subi  I'opera- 

tion  de  la  cataracte,  a  recouvre  a  la  fois  le  vue  et  la  raison.  Mont- 
pellier  Med.,  Nov.;  Ann.  d'Oc,  XXXIV,  p.  246. 

887.  Schartow,  E..  Historia  operationum  ad  cataractae  lenticularis  san- 

ationem  spectantium.     Gryphiae,  1800.    Dissert. 

888.  Bader,  Report  on  cases  of  cataract  treated  by  "linea'r  extraction," 

at  R.  L.  O.  H.,  from  April,  1857,  to  May,  1860.    O.  H.  R.,  II,  p.  346. 

889.  Ammon,  v.,  Acyclia,  irideremia  et  hemiphakia  congenita.    Nova  acta 

Acad.  Caes.  Leop.  Carol.,  t.  XXVII,  u.  Ann.  d'Oc.  XLIII,  p.  282. 

890.  Coruuty,  De  la  paracentese  de  I'oeil,  6,  Phlegmon  de  I'oeil  a  la  suite 

des  operations  de  cataracte.    Ann.  d'Oc,  XLIV,  p.  92. 

891.  Oeil  atteint  de  cataracte  double,  dite  polaire,  developpee  dans  la 

capsule  anterieure,  et  de  cataracte  du  centre  de  la  lentille  cristal- 
line,  avec  rayonnement  sur  la  face  posterieure  du  crystallin.  Gaz. 
des  Hop.,  p.  322,  u.  Ann.  d'Oc,  XLIV,  p.  146. 

892.  Sichel.  Du  cephalostat,  appareil  servant  a  tixer  la  tete  pendant  les 

operations  de  cataracte  qu'on  pratique  chez  les  enf;'.nts.  Bull, 
de  Ther..  LTX.  p.  141.  u.  Anu.  d'Oc.  LIV.  p.  149. 


457 
1860.    89:'..  Courss.'iant.  Catjir.i(t.>;  nouvciu  phmimI."  .r.-xtraclion.     Soc.  fie  Med. 
Prat.,  7  Juin,  u.  Ann.  d'Oc.  XXXIY.  p.  240. 

894.  Leport,  Fmn-che  a  deux  branches  pour  la  fixation  dc  I'ooil  dans  les 

operations  qu'on  pratitiuo  sur  cet  orfiane.  in  "Guide  pratique  pour 
bien  executer  I'oper.  de  oat.  par  extraction."  Paris  et  Rouen. 
Ann.   d'Oc,   XLIV,  p.  247. 

895.  Quagliuo,  Taixation  spontanee  du  crislalliu.  etc.     (Jioru.  d'Oiithalm. 

Ital.  et  Bull,  de  Therap.,  Avril. 
89(;.  Desmarres,    Extraction    voluiuinosor   cataracten    durcli    den    linear- 
schnitt.     Allg.  Wien.  Med.  Zeitg.,  No.  27. 

897.  Hogg,  J.,  Luxation  du  cristallin  dans  la  chambre  anterioure  par  suite 

d'un  eternument  prolonge.  extraction  guerison     Lancet.  June. 

898.  Teisser,  Luxation  du  cristallin  dans  la  chambre  anterieure  a  la  suite 

d'une  operation.    Rev.  de  Therap.  Med.  Chir.,  No.  11. 

899.  Blanc,   Questions   cliniques  relatives   a  la  cataracte.     (Jaz.   Hebd., 

No.  30. 

900.  Kuchler,  H.,  Die  umlegung  des  grauen  staars  durch  die  sehnenhaut, 

ihre  gefahren  und  die  mittel  denselben  vorzubeugen.  Deutsch. 
Klin.,  No.  31,  33. 

901.  Fano,  Luxation  sous-eonjonctivale  du  cristallin.     Oaz.  des  Hop.,  No. 

152. 

902.  Squere,  W.  J.,  De  la  cataracte    et    de    son  traitement    chirurgical. 

Brit.  Med.  Journ.,  Sept.  15,  22. 

903.  Desiuarres,  Fils,  amblyopic  avec  signes  do  nyctalopie  par  agenesia 

incomplete  du  cristallin,  observee  chez  trois  freres.    Mon.  des  Sc. 
Med.,  1138,  u.  Ann.  d'Oc,  XLV,  p.  196. 
1861.    904.  Critchett,   Practical  observations  upon  congenital  cataract.     Opth. 
Hosp.  Rep.,  Ill,  p.  137  and  183. 

905.  Pagenstecher,  Die  verlagerung  der  pupille  durch  iridodesis.     Arch. 

f.  Opth.,  t.  VIII,  A.  1,  p.  192. 

906.  MuUer,  E..  Rcitrag  zur  kehre  der  spontanea  llnsenluxation.     Ibid, 

p.  166. 

907.  Schweigger.  Ueber  entstehung  des  kapselstaars.     Ibid,  p.  227. 

908.  Heddaeus.  Partieller  schichtstaar.    Ibid,  p.  315. 

909.  Wilde.  Congenital  diseases  and  malformations  of  the  dioptric  media. 

Dubl.  Quart.  Journ..  No.  01.    February. 

910.  Hulke.   Cases  of  congenital   cataract  treated  i)y  iridodesis.     Opth. 

Hosp.  Rep.,  III.  p.  339. 

911.  Poland,  On  the  use  of  forceps  in  extraction  of  cataract;  France's 

method.    Opth.  Hosp.  Rep.,  Ill,  p.  268. 

912.  Swain,  Case  of  cataract  and  diabetes.  Optli.  Hosp.  Rep.,  Ill,  p.  331. 

913.  Ritter,  Folger  de  reclination  und  discission.    A.  f.  O..  VIII,  1,  u.  Ann. 

d'Oc,  p.  323. 

914.  Lecorche.  De  la  cataracte  diabetique.     Arch.  Gener.  de  Med.,  Mai; 

Ann.  d'Oc.  XLVIII.  p.  100. 


458 
1861. 


915.  .laser,  E.  v.,  Spontaue  beiluus-  von  tnibungeu  in  (Ut  niensfhlichen 

linse.    Ot'sterr.  Zeitschr.  f.  Prakt.  Ileilk.,  No.  31  u.  32. 

916.  Tedesclii,  Nonveau  precede  pour  operer  I'extraotion  de  la  cataracte. 

Un.  Med.,  Avril;  Ann.  d'Oc,  XLV,  p.  280. 

917.  Heymann,   Spoutaue  freibeweglichkeit  der  linse.     Zeitsch.  der  Ge- 

sellsch.  f.  Natur.  uud  Heilkunde.    Dresden,  w.  Ann.  d'Oc,  XLVIII, 
p.  189. 

918.  Fischer,  De  la  luxation  spontanee  du  cristallin.     Arcb.  Gen.  de  Med., 

Janv..  u.  Ann.  d'Oc,  XLVI,  p.  83. 

919.  Quadri,  A.,  Note  sur  un  cas  de  traitement  de  la  cataracte  sans  oper- 

ation.   Ann.  d'Oc,  XLIV,  p.  202. 

920.  Fa  no,  Sur  la  sortie  premature  du  niyeau  du  cristallin  dans  la  cata- 

racta  moUe  operee  par  extraction.    Gaz.  des  Hop.,  p.  391,  u,  Ann. 
d'Oc,  XLVI,  p.  220. 

921.  Rivaud-Landrau,  Statistique  d'operations  de  cataracte.     Gaz.  Med. 

de  Lyon,  p.  450. 

922.  Zehender,  Die  Icrankheiten  des  linsensystems.    Handbuch  der  Augen- 

heilkunde.    Erlangen. 

923.  Saemisch,  Zur  operation  der  cataract.     Wurzb.  Med.  Zeitschr..  II, 

p.  272. 

924.  France,  Observations  de  cataracte  diabetique.    Med.  Times  and  Gaz., 

9  Mars. 

925.  Cade,  Am.,  Cataract  congenitale  double  operee  a  Tage  de  18  ans. 

Bullet,  de  Therap.,  Juin. 

926.  Demarquay,     Keratotomie     superieure,    procede     sous-coujonctival, 

keratotomie  superieure  et  iridectomie.    Gaz.  des  Hop.,  No.  53. 

927.  Peachy,  H.  D.,  Guerison  spontanee  d'une  cataracte.     Amer.  Med. 

Chir.urg.  Rev.,  Mars.,  p.  317. 
928  Gouriet,   Resorption  lente  ot  progressive  du  cristallin;   daltonisme; 
des  diverses  methodes  de  scleronyxis.    Gaz.  des  Hop.,  No.  113,  u. 
Ann.  d'Oc.  XLV,  p.  166. 

930.  Giraud-Teulon,  Des  mouvements  de  concentration  lateral  de  I'appa- 

reil  cristallinien  pour  satisfaire  a  I'unite  de  la  vision  binoculaire, 
fant  lors  de  I'intervontion  des  prisraes  ou  des  lunettes  que  dans 
certains  cas  pathologiques.    Ann.  d'Oc,  XLV,  p.  113. 

931.  Slchel,  Materiaux  pour  servir  a  I'etude  anatamique  de  I'opthalmle 

periodique  et  de  la  cataracte  de  cheval.    Ann.  d'Oc.  XLVI,  p.  181. 
9.32.  Prault,  Operation  des  grauen  stanrs  bei  einem  r2   jagrigen  knaben. 

Allg.  Wien.  Med.  Ztg.,  No.  37. 
933.  Serres,  Operation  modiee  de  la  cataracte.    Gaz.  Hebd.,.No.  38. 
1862.    934.  Meyer,  Ignaz,   Die  kriebel-kraukheit  als  ursaclie  der  staarbildung. 

Wien.  Wochenschr.,  No.  47,  1861,   u.  Arch.   f.  Opth..  VIII,  A.  2, 

p.  120. 
dSn.  Sperino,    Etudes    cliniques    sur    I'evacuation    repetee    de    Thumeur 

aqneuse,  etc    Turin,  in  8o. 


459 
1862.    U'\r>.   Swain.   Caso   of  cilanict    and   (liah.-tcs.     (}\>\U.    IIosp.    ilvp..    No.   17, 
p.  331. 

937.  Graefe,  A.  v.,  Cystoido  vt-rnaihun^'  b.-i  iridrctomie  wej.'on  glaucom. 

A.  f.  O.,  VIII,  2,  p.  263. 

938.  Alessi.  Cause  de  la  cataracte  cliez  les  paysu'-s  des  l)ords  du  Don. 

Ann.  d'Oc,  XLVII,  p.  30. 
93J>.  Mooren,  Die  vermindorteu  gefahren  ciiifr  llornhautvereitcrung  bel 
der  Staarextractiou.    Berlin,  in  So. 

940.  Jamin,  A.,  Du  broiemont  de  la  cataracte.  Gaz.  des  Hop..  No.  18. 

941.  Smith,  G.,  De  I'abaissenu'nt  de  la  cataracte  aux  Indes.     Edinb.  Med. 

Journ.,  p.  101.     Fevr. 

942.  Walton,  H.,  Operation  pour  la  resorption  de  la  cataracte  dure.    Lan- 

cet,  14  Avril. 

943.  . ,  De  la  discission  de  la  cataracte.    Brit.  Med.  Journ.,  7  .Tuin. 

944.  Browne,  Observation  de  cataracte.    Dubl.  Jouin.   :Mai 

945.  ,  Cataracte  congenitale.    Ibid.    November. 

946.  Stoeber,  Cataracte  dlabetique.  extraction  lineaire.     Gaz.  de  Strasb., 

No.  5  et  6. 

947.  Chausit,    A.,    Luxation    sous-eonjonctivale    du    cristalUn.      Gaz.    des 

Hop.,  No.  101. 

948.  Gerardi,  Ueber  Staaroperatlom-ii  auf  deni  I.ande.    Wien.  Med.  Halle, 

No.  40. 

949.  Hart.  E.,  Deux  cas  de  cataracte  et  extraction  par  la  section  iferieure, 

etc.     Lancet,  5,  Avril,  Oct.  et  Nov. 

950.  Tetzer,  Max,  Ueber  cataracta.    Allg.  Wien.  Med.  Zeitg.,  No.  1-4. 

951.  Alessi,  Kesultats  des  operations  de  cataracte  et  relation  d'un  cas 

d'extraction,  dans  lequol  la  pointe  du  keratome  s'est  brisee  dans 
la  cornee. 

952.  Rivaud-Landrau,  Statistiquo  d'operatious  de  cataractes  (2317).    Ann. 

d'Oc,  XLVII,  p.  65. 

953.  Alessi,   Un  aveugle-ne  sourd-muet,  gueri   de  la  cecite  congenitale. 

Ann.  d'Oc,  XLVII,  p.  112. 

954.  Lanne,  Pince-aiguille  a  cataracte.     Gaz.  des  Hop.,  P'evr.,  u.   Ann. 

d'Oc,  XLVII,  p.  109. 

955.  Coursserant,  Incision  de  I'iris  dans  la  keratotomie  superieure.    Gaz. 

des  Hop.,  No.  132. 

956.  Desormeaux.  Blessure  du  cristallin.     Ibid. 

957.  Ilulme,    Luxation   du   cristallin,   avec   transformation   cataracteuse 

Chez  neuf  membres  d'une  famille.    Lancet,  23  Dec. 

958.  Nelaton,  Cataracte  double,  extraction  lineaire.  Gaz.  des  Hop.,  No.l45. 
1863.    959.  .Tacobson.   Ein  ncnies  gefahrloses  operations  verfahrcn  zur  hellung 

des  grauen  Staars.    Berlin,  in  8o. 
960.  Boiling,  A.  Pope,  A  case  of  laminar  cataract.    Opth.  Hosp.  Rep.,  IV, 
p.  79. 


46o 

1863.    961.  Boiiissou,    D'lm   t-as   partirulier   ile   diabet«'   avec   cataracte   double. 
Montpellier  Med.,  Janv. 

962.  Wecker.  Iridesis  in  einem  falle  von  doppelter  linsenluxation.    Klin. 

Monatsbl.,  Maiz,  xi.  Gaz.  des  Hop.,  No.  22.     Ann.  d'Oc,  XLIX, 
p.  159. 

963.  Knapp.  Erfolgreiehe  pupillenbilduug  bei  eiuer  durcli  einen  Stoss  dis- 

locirten  linse.     Ibid.    Avril. 

964.  Graefe,  A.  v.,  Extraction  bei  maiastisflieui  auge,  uinscbriebene  sup- 

puration.    Ibid.     Avril,  Juin. 

965.  Hays,  Remarks  on  cataract.    Aiuer.  Journ.  of  Med.  Science.    .Juillet. 

966.  Sichel,    Sur  une   espece  particuliere   de   delire   senile,   qui   survient 

quelquefois  apres  I'extraction  de  la  cataracte.    Un.  Med.,  Janv. 

967.  Borelli,  Nouveau  cas  de  delire  nostalgique  consecutif  a  Toperation 

de  la  cataracte.     Giorno  d'Opth.     Ital. 

968.  Becker,  F.  S.  v.,  Untersuchungen  uber  den  bau  der  linse  bei  den 

Meuscbeu.  und  Wirbelthieren.    Arch.  f.  Opth.,  IX,  A.  2,  p.  1. 
968.  Graefe,  A.  v.,  Ueber  die  zweckmassigkeit  einer  breiten  discissions- 
nadel  bei  operation  flussiger  cataracten.     Ibid,  p.  43. 

969a.  ,Extraction  fremder  Korper,  reclinirter  linsen  und  entozoen  aus 

dem  glaskorperraum.    Ibid,  p.  79. 

970.  Knapp,  Beiderseitige  linearextractiou  eines  d'abetischen  Staars.   Ze- 

heuder  Klin.  Monats.,  168,  u.  Ann.  d'Oc,  LI,  p.  50. 

971.  Graefe,  A.  v.,  Ueber  den  druckverband  bei  augenkrankheiten.    Ibid, 

p.  ni. 

972.  Hildrige.  Sur  le  traitemeut  de  la  cataracte  par  Tevacuation  frequente 

de  I'humeur  aqjieuse.     Gaz.  Med.  de  Paris,  p.  507. 

973.  Quaglino,   Sulla  cura  medica  della  cataratta  et  sugli  effecti  della 

paracentesi  corneale  repetuta,  etc.  Ann.  Univ.  di  Med.  Milano,  181. 

974.  Masen,  Cataracte  trauma  tiqne.  e  tc.     Bull,  de  la  Societe  Medic,  de 

Gand.    Mars. 

975.  INIauduy,  De    I'operation    de  la  cataracte    par    extraction    lineaire. 

These,  de  Paris. 

976.  Eberhardt,    Memoire  sur  la    cataracte    lamellaire.     Nantes,  in    8o, 

p.  15,  Gaz.  des  Hop.,  No.  64. 

977.  Froebelius.   Cataractbildung  durch  vier  geueratiouen  einer  familie 

hindurch.     Petersb.  Med.  Zeitschr.,  No.  8  u.  9. 

978.  Hart,  E.,  Gas  d'extraction  et  de  discission  de  cataracte.     Lancet  II, 

13  Mars  et  16  Avril. 

979.  Scliirmer.   Uelier  spontaue  luxation  durchsichtiger  linsen.     Greifs- 

walder  Beitr.,  I,  p.  77. 

980.  Lanne.  Delire  nerveux  a  la  suite  de  l'(>i)erati(»n  di'  la  cal.ir.u'te.    Gaz. 

des  Hop.,  No.  57. 

981.  Magne,  Delire  apres  I'operation  de  la   cataracte.   Bull,  de  Therap., 

30  Mai. 


46 1 
1863.    082.  Lausier.  Luxation  du  (rist:illiii  diiiis  l.i   .liMiiilur  .inlci-ieiiro.     Gaz. 
(los  Hop.,  No.  ST. 
OSa.  Carter.  Rob,  T^es  nouvcnux  |.i(m(mIcs  (Icxtr.iclioii  dc  oatnracto.    Med. 
Times  and  Gaz..  24  Oct. 

984.  Beelver.  O..  Function  dor  ciliarlortsatze.    AVifUcr  Med.    .lalirbucher. 

985.  Laurence,  Irri.aalions  apres  I'extraction  de  la  cataracte.    Brit.  Med. 

Jouru.     .luillel. 

986.  Saint-IIdepliont.  'ri'.-iilcniciit  dc  hi  <-:it:ir;ici.'  smiis  (.iteration.     Revue 

de  Tlier..  No.   Xo,  402. 

987.  Warlomont,  Cas  de  mort  ;i  la  suite  d  iiiie  (.i.er;iti<iii  de  «:itaracte  par 
,  discission.     Ann.  d'Oc.  lA.  p.  2:!9. 

't  1864.    988.  Critehett,  A  ease  of  congenital  cataraet  tre.-iied  by  iridesis.  in  which 

*  some  nioditieations  wei-e  inti-oduced  in  tlie  ojieration.    Opth.  Hosp. 

Rep.,   IV,   p.   IW. 
■    '  989.  Zehender,  Ueber  die  zweckniassigste  sclmi'ideform  der  zur  lappen- 

sehnitt  extraction  dienenden  messer.     Klin.  Monatschr.,  p.  73. 

990.  Leuckardt,  ITeber  die  parasiten  der  mensehl.  linse.     Ibid,  p.  86. 

991.  Melchior,  Sur  le  developpenient  de  la  cataract*' dans  le  diabete.  Ann. 
d'Oc,  LI.  p.  262. 

992.  Servais.  Observations  de  cataracte  produite  par  la  foudre.  Recueil 
de  Memoires  de  :Med..  de  Chirurg.  et  de  Pharm.  de  Paris,  p.  229. 

09.1.  .lacobson.  Zur  lehre  der  cataract  extraction  niit  Lappenschnitt. 
Arcli.  f.  Opth.,  X.,  A.  2.  p.  7S. 

994.  — .   I'eber  die  cataract  (.iteration   niit    Lappenscluiitt.      Ibid,   IX, 

A.  2,  p.  147. 

995.  ,  Ueber  cataract  extraction.  Klin.  Monatsbl.,  p.  30. 

996.  Knapp,  Ueber  behandlung  des  grauen  Staars.  Zweiter  .Tahresber. 
Heidelberg. 

997.  Arlt.  Verkalkte  linse.  (Jlaskorperblutung.  Klin.  Monatsbl..  1864. 
p.   364. 

998.  Graefe,  A.  v..  I'eber  die  kapseleroffnung  als  voract  der  Staaroper- 
ation,  nebst  bemerkungen  niter  die  Wald  des  operationstermins. 
Ibid.  p.  2(10. 

090.  Manhardt,  Ueber  extraction  inn-eifer  cataracten.     Ibid.  p.  408. 

1000.  Bauzon,  De  I'extraction  lineaire.     These,  de  Paris. 

1001.  Critehett,  Description  d'un  nonvel  instrument  pom*  I'extraction  de 
la  cataracte.     Lancet,  et  .\nn.  d'Oc,  LI,  p.  44. 

1002.  — ,  Do  I'extraction  de  la  cataracte  an  moyen  de  la  curette.    Ann. 

d'Oc,  LII,  p.  115,  u.  Klin.  :\Ionatsbl..  p.  340. 

100.'^.  Lawson.  Traumatic  cataract  produced  without  rupture  of  the  ex- 
ternal coats  of  the  eye.     Opth.  Hosp.  Rep.,  IV,  p.  170. 

1004.  Pridgin  Teale.  A  suction  curette  for  tlie  extraction  of  soft  cataract. 
Ibid,  IV,  p.  107. 

1005.  Froebelins,  Falle  von  Staarextraction  mit  einem  vorschlage  zur 
modification  derselben.    Petersb.  Med.  Zeitschr.,  p.  28. 


462 

1864.    1006.  Hai-t,  E.,  De  la  cataraote  au  point  de  vuo  de  diagnostic  et  du  traite- 
ment.    Lancet,  15  Avril. 

1007.  Jarjavay,  Cataract  oapsulaire  secondaire.    Gaz.  des  Hop.,  No.  12. 

1008.  Jouou,  Note  sur  les  cataractes  strat.  et  sur  leur  traitement.   Nantes, 

in  So,  p.  11. 

1009.  Bader,  Two  i-ases  of  diabetic  cataract.    Opth.  Hosp.  Rep.,  IV,  p.  288, 

1010.  Rydel,  Luc.  Stationaler  kernstaar  odei-  scliichtstaar.    Wien.  Med. 

Ilalle.  Nos.  7,  8,  10,  11,  13.  1.5  u.  16. 

1011.  Singer,   Mat.,   Zwei   falle   von  pyramidenstaar.     Ibid,   Nos.   14,   17, 

19  u.  20. 

1012.  Sicliel,  Ueber  druclvverband  nacli  Staaroperationen.   Deutscli.  Klin., 

No.  4. 

1013.  Blessig.Vergleichende  casuistik  dcr  einfachen  und  der  mit  iridec- 

tomie  verbundenen  Staaroperationen.  Petersb.  Med.  Zeitschr., 
No.  3. 

1014.  Lawson,  G.,  De  la  cataracte  congenitale.    Brit.  Med.  Journ..  9  Juill. 

1015.  :Martin,  E.,  De  I'operation  de  la  cataracte  et  du  procede  oderatoire 

de  reclinaison  par  la  cornee  keratoyxis.     Paris,  in  80,  p.  38. 

1016.  Massol.  A.,  Nouvelle  niethode  de  traitement  a  suivre  apres  I'oper- 

ation de  la  cataracte.     Pnris.  in  8o.  p.  16. 

1017.  Walton,  H.,  Cas  de  cataracte.     Brit.  Med."  .T-«rtiru..  7  May. 

1018.  Hunt,  Ossification  du  cristallin.     Americ.  Jourc.  Juill,  p.  94. 

1019.  Hasner.  d'A.,  Ueber  die  glaskori)erpunction  bei  der  extraction  des 

Staars.     AVien.  Med.  Wochenschr.,  No.  42. 

1020.  Mattioli,  G.  B.,Studii  che  conducono  alia  possibilita  della  guarizione 

della  cataratta  incipiente  immature  dei  giovani,  col  ridurle  a  cata- 
ratte  traumatiche  et  far'e  absorbirc  a  mezzo  della  paracentesl 
oculaire.    Yenezit,  in  So,  p.  14. 

1021.  Taylor,  Ch..  De  I'extraction  de  la  cataracte.     Brit.  Med.  Journ.,  12 

November. 

1022.  Wecker  et  De  la  Croix,  H.,  Luxation  du  cristallin  cataracte,  obliter- 

ation de  la  pupille,  etc.     Gaz.  des  Hop.,  No.  8. 
1S65.    1023.  Jacobson,  Ueber  die  zulassigkeit  des  chloroforms  bei  Staaropera- 
tionen.     Arch,  fur  Opth.,  XI,  A.  1,  p.  114. 

1024.  Moers,  Beitrage  zur  pathologischen  anatomie  der  linso  nach  ver- 

suchen  an  thieren.    Virchow's  Arch.,  XXX,  p.  45. 

1025.  Bence,  Jones,  Proceedings  of  the  Royal  Institution  of  Great  Britain, 

Vol.  IV,  Part  VI,  No.  42.  Octobei'.  (Experimente  uber  das  spate 
auftreten  resorbirter  stoffe  in  der  linse.  besonders  von  koh^ensau- 
rem  lithium.) 

1026.  Braun,  Beitrag  zur  heilung  des  harten  staars.     Ibid.  p.  200. 

1027.  Bessac.  J.   M..   Etudes  sur  I'etiologie  de  la  cataracte.     These,  de 

Paris,  in  4o,  p.  37. 

1028.  Bouneval,  (Jaligny  de.   De  la  <;i(:n-aote  zonulaire  et  de  sou  traite- 

nu-iit.     'I'licsc.  de  P:iris.  in  4o. 


463 

1865.  1029.  raffoiistecher.  C,  Uebor  vt'ilftzmij.'.'n  d.-r  lins.-nkai.sol.  Kiln. 
MoiKitsbl.,  iu  4o,  i».  71. 

loao.  Sophus-Davidseii,  Zur  Ichiv  voin  s.hiolitstMiir.  I uaug.  Dissert.  Zu- 
rich. 

10.Sl.Oalezowski.  Luxation  du  cristallin  sous  Ic  ooiuonctivo  ot  de  la  cata- 
racto  par  extraction.  Ann.  d'Oc,  LIU,  p.  19G. 

1032.  Wcdter,  Extraction  do  la  cataracte  sans  ouvcrtm-c  dc  la  cristal- 

loidc.     Gaz.  Hcbd..  No.  30. 

1033.  .  De  retiolojjie  de  la  cataracte.     Ann.  dOc,  LIV.  p.  16. 

1034.  Guerserant.  P.,  De  la  cataracte  chez  les  enfants.    UuUet.  de  Tlierap., 

15  Fevr. 

1035.  Laurence,  Z.,  Do  I'cxtraction  d<'  la  <-ataracte  dai»res  Moorcn.    Brit, 

Med.  .loiu-u.,  11  Fevr. 
1030.  Walton.  IL.  Observations  de  cataracte.     Med.  Times  et  Gaz.,  8  Avr. 

1037.  Zeliender.  Ueber  staarmesserfornien.     Klin.  :Monatsbl.,  Ill,  p.  122. 

1038.  Stephau,  Tnnnnatiscli(>  luxation  de  lins.'  niit  cataractbildung.    Ibid, 

p.  164. 

1039.  Berlin,  Zur  statistik  der  Jacobson's  cheu  extractions-methode.   Wur- 

temberg.   Corresp.,  B.  1,  No.  19. 

1040.  Critchett,  On  the  removal  of  cataract  by  the  scoop-method,  or  the 

method  by  ti-action.     Opth.  Hosp.  Rep..  IV,  p.  315. 

1041.  Bowman.  On  extraction  of  cataract  by  a  traction  instrument  with 

iridectomy;  with  remarks  of  capsular  obstructions  and  their  treat- 
ment.   Ibid,  p.  332. 

1042.  Kruse,  II.,  Ueber  cataractbildung.    Zeitschr.,  f.  Rat.  Medic,  XXIV, 

p.  261. 

1043.  Salomon,  A'ose.  Annular  synechia  and  cataract,  etc.     Opth.  Rev., 

No.  5,  p.  28. 

1044.  Graefe,  A.  v..  Remarks  on  traumatic  cataract.     Berl.  Klin.  Woch- 

enschr.,  u.  Opth.  Rev.,  No.  6,  p.  37.   Ann.  d'Oc,  LIV,  p.  270. 

1045.  Kuchler,   Ueber  die  form   der  staarmesser;   uber  nachbehamllung 

nacb  der  staaroporation.     Deutsch.  Klin.,  Nos.  39,  40  u.  43. 

1046.  Moon,    Observations  sur   I'extraction   linealre   de   cataracte   molle, 

suivie  d'un  decoUement  de  la  retine.    Ann.  d'Oc,  LIII,  p.  250. 

1047.  Taylor,  Cinq  cas  de  cataractes  traites  par  "'extraction  suivant  la 

methode  de  Mooren.    Ann.  d'Oc,  LIII,  p.  2.58. 

1048.  Holmes,    Observations    de    cataract   pyramidal.      Anier.    Journ.    of 

Opth.,  II,  14. 

1049.  Szolvalsky,   Cristallin   luxe   sous   la    ron.jonclivc.     Ann.    d'Oc,   LIV, 

p.  212. 

1050.  Wecker.    Luxation    du    <  rist.-illin   et    c.itaractes   reconnues,    malgre 

I'obliteration  de  la  impille  ii  travers  I'iris  atroithie.  Gaz.  des  Hop., 
8,  29.    Ann.  d'Oc  \.\\.  ]>.  125. 

1051.  Lawson,    F..   A  case  of  dislocation   of   tiie  lens  into  the  anterior 

chamber;  excessive  pain  two  yea  is  after  the  in.iury  and  loss  of 
sight;  extraction  of  t  lie  lens  foUowed  by  immediate  posterior 
hemorrhage.     Opth.  IIosp.  Rev..  IV,  p.  .379. 


464 

1865.    1052.  Prie,  Obscrva lions  de  oataracte.     I*aris,  iu  80,  p.  11. 

1053.  Graefe,   A.   v..   T'elK-r   nioililiciite  lluoarextraotion.     Arch.   f.   Opth., 

X,  A.  3,  p.  1. 

1054.  Ullersperger.   Kleiue  mittln'iluny   fur  die  ^'oscliitlitc  der  operation 

des  graiien  staars.     Ibid.  XI.  A.  2,  p.  2tJ2. 
1806.    1055.  Adams,  Math.,  The  modern  methods  of  dealing  with  cataract.   Brit. 
Med.  Journ.,  13  Janv. 

1056.  Monte,  Michele  de.  Note  sul"  inrtiuinnatione  del  cristallino  e  della 

sua  eapsula,  11.    Morgagni.  I. 

1057.  Follin,  Des  diverses  methodes  operatoires  de  la  f-ataracte.     Arch. 

Gener.  de  Med.,  Fevr.,  p.  212. 

1058.  ,  Luxation  congenitale  du  eristallin.     Gaz.  dez  Hop.,  No.  20. 

1055.  Martin,  E.,  De  I'extraction  de  la   calaracte  duie  au  moyen  de  la 

eurette-erigne.     Gaz.  des  Hop.,  No.  9. 

1060.  Paikrt.  A..  liUxation  u.  fractur  der  linse  in  folge  von  verletzung. 

AUg.  Milit.  Arztl.  Ztg.,  No.  4. 

1061.  Hart,  E.,  Clinical  lectures  on  cataract,  with  reference  to  improved 

methods  of  diagnosis  and  treatment.     Lancet,  21  May. 

1062.  Hasner,   d'A.,   Klinische  vortrage   uber  augenheilkunde.    3,   Abtb. 

Die  krankheiten  des  linsensystems.     Prag,  in  So,  )>.  106. 

1063.  Lnca.  Dom.,  De  I'extraction  de  la  cataracte  capsulaire  et  capsulo- 

lenticulaire.     II.  Morgagni,  No.  2  et  3. 

1064.  Bowman.  Cases  of  malformed,  misplaced  and  dislocated  lenses,  in 

some  of  which  glaucomatous  symptoms  were  developed.     Opth. 
Hosp.  Rev.,  y,  p.  1. 

1065.  Samelson,  A..  A  case  of  pyramidal  cataract,  with  microscopic  ex- 

amination (by  Prof.  C.  Schweiggei'l  of  the  lens  after  extraction. 
Ibid,  p.  48. 

1066.  Cowell.  G.,  Two  cases  of  traumatic  cataract,  possessing  some  inter- 

esting points  of  diagnosis.     Ibid,  p.  131. 

1067.  Meckeand,  Extraction  des  cataracte  moUes  par  succion.    Brit.  Med. 

Journ.,  30  Juin. 

1068.  Testelin,  Luxation  sous-conjouctivale  du  eristallin.    Gaz.  des  Hebd., 

No.  31. 

1069.  Arlt,  Ueber  v.  Graefe's  linearextraction  der  cataracte.     Wien.  ISIed. 

Wochenschr.,  No.  24. 

1070.  Samelson,  A.,  v.  Graefe's  modilicirte  linear  extraction.     Deutsch. 

Klin.,  No.  7. 

1071.  Kuchler,  Ueber  extraction  des  staars.  Ibid,  37-39. 

1072.  Classen,  I'eber  staaroperatiou.     Ibid,  No.  43. 

1073.  Fano,  De  I'operation  de  la  cataracte.     Gaz.  des  Hop.,  No.  124. 

1074.  Sichel.  Du  mode  operatoire  qui  convient  le  mieux  aux  cataractes 

(•.•il)suhiires    centrales    et    capsul.-iires-lenticulaires    centrales,    etc. 
Bull,  (le  Therap.,  15  Sept. 


465 

18G«;.  1075.  Pafit'iislccluT,  rclu-r  (lit-  cxtniclion  d.s  -r.-mcii  suiiirs  bei  uneroff- 
notcr  kapsel  (lurch  tlcu  sclcnilschiiil t.  Kliii.  licohacht.  aus  der 
ausonluMlanstalt  zu  Wicsbadt-ii.  Ill,  p.   1. 

1076.  Iwanofl".  Bcltras  zur  patliolouisdu'ii  anatomic  dcs  hornhaut  und 
liuseiu'pithcls.     Pagcustcchci-.   Kliii.   Hcobaclil.,   Ill,  p.  126. 

1077.  Matrion,  G..  Des  iudlcatious  dc  ropcialiou  de  la  cataracte  et  du 
choix  de  la  methodc  opcratolrc.     These,  dc  Paris,  in  4o,  p.  70. 

1078.  Vitrac,  E..  Etude  sur  le  traitcnicnt  de  la  cataracte  par  discission. 
TlU'S«'.  de  I'aris.  in  4o.  p.  .">:>. 

1079.  Arguillo.  Marcello.  De  I'operation  de  la  cataracte  par  ''extraction 
lineaire.     These,  de  Paris,  in  4o.  p.  3»!. 

1080.  Keand.  M..  Case  of  extraction  of  soft  cataract  in  both  eyes  by  suc- 
tion.   Brit.  Med.  Journ.,  .30  ,Tuin. 

1081.  Hutchinsin,  Cataracts  in  childhood  fully  developed  in  one  eye. 
Operation  on  one  eye  at  the  age  of  fifteen.  No  sight  obtained, 
owing  to  atrophic  changes  in  optic  nerve.  Pupil  of  this  eye  very 
active.     Opth.  Hosp.  Rep.,  V,  p.  216. 

1082.  Nermann,  Spontaneous  rupture  of  film  of  cai)sule  three  months 
after  extraction  of  lens.     Opth.  Hosp.  Rep.,  V,  p.  223. 

1083.  Hutchinson,  Operations  for  solution  of  senile  cataracts  commenced 
at  an  early  period,  without  allowing  the  cataract  to  ripen.  Opth. 
Hosp.  Rep..  V,  p.  329. 

1084.  Walton.  Haynes,  Black  cataract.     Brit.  Med.  Journ..  27  January. 

1085.  Bouyer,  Cataracte  trauniatique  avec  synechia  posterieure.  Gaz. 
des  Hop.,  No.  118. 

1086.  Desmarres,  A.,  Des  applications  de  Tiridectomie  au  traitement  de 
la  cataracte.    These,  de  Paris,  in  4o,  p.  95. 

1087.  Tillaux,  Luxation  sous-con jonctivale  du  cristallin.  Gaz.  des  Hop., 
No.  127. 

1088.  Wells,  Lectures  on  cataracts  and  the  modern  operations  for  its 
treatment.  Med.  Times  et  Gaz.,  17  Oct.,  10  Nov.,  S  Dec.  u.  22  Dec. 

1089.  Graefe,  v.,  Nachtragliche  bemerkungen  uber  die  modificirte  linear 
extraction.    Arch.  f.  Opth.,  XH,  A.  1.  p.  150. 

1090. ,  Cysticercus  in  der  linse.     Ibid.  XII,  A.  2,  p.  191. 

1091.  Windsor  and  Little.  Th.,  Cases  of  flap  extraction  of  cataract  under 
chloroform.     Opth.  Rev.,  No.  8,  p.  305. 

1093.  Dyer,  Fracture  of  the  lens  of  one  eye  and  of  the  anterior  capsule 
of  both  eyes  from  death  by  violent  hanging.  Trans,  of  the  Amer. 
Soc,  Boston.    Juin. 

1094.  Hirschmann,  Luxatio  lentis  spontanea.     Klin.  Monatsbl.,  IV,  p.  98. 

1095.  Borelli,  Osservazione  di  doppia  cataratta  molle  risanta  i-apidamente 
coir  estrazione  lineare.     Giorno  d'Oft.  Ital.,  IX,  p.  180. 

1867.    1096.  Milliot,  Memoire  sur  la  regeneration  du  cristallin.    Bull,  de  I'Acad. 
des  Sciences.  28  Janv..  et  Gaz.  des  Hop..  No.  O. 
1097.  Knapp.  Metastatische  clioroiditis.     A.  f.  ().,  XIII. 


I 


466 

1867.    1098.  Gouriet.  Cas  reuiarquable  de  luxation  spoutauee  du  cristalliu  et  de 
sa  capsule  dans  la  chanibre  anterieure.    C4az.  des  Hop.,  No.  43. 

1099.  Monoyer.  Une  extraction  de  la  cataracte  dans  un  cas  de  luxation 

spontanee    et    d'opacitication    du    cristallin,   etc.     Gaz.   Med.   de 
Strasb..   No.  14. 

1100.  Paoli.  Cesare,  Del  metodo  operative  pr<'feri»)ili  in  vari  casi  di  cata- 

ratte.    Firenze,  in  8o. 

1101.  Simi,  A.,  Supra  uno  scritto  des  c.  s.  Prof.  Cesare  Paoli  intitulata 

sul  methodo    operatorio    preferibile    nel  vari  casi  di    cataratta. 
Lucca,  in  So,  p.  9. 

1102.  Taviguot,  Traitement  df  la  cataracte  par  I'extraction  directe.    Nou- 

veau  precede.     Abeille  Med..  No.  48. 
1013.  Walton.  H.,  Extraction  de  la  capsule  opaque  apres  la  perte  du  cris- 
tallin.    Brit.  Medv  Journ.,  2  Fevr. 

1104.  Stepban,   Erfahrungen   mit  studieu   ubcr  die   staaroperation.      Er- 

langeu.  in  8o,  p.  62. 

1105.  Rydel  u.  Becker,  Spontane  aufhellung  der  catar.  traumat.;  cataract. 

caps,  centr.  anter.  mit  cat.  nuclearis;  zwei  seltene  staarformen. 
Voy.  Ber.  uber  die  Augenkliu.  d.  Wien.  Univers.    Vienne,  In  So. 

1106.  Macnamara,  linear  extraction  of  t  be  lens.  Opth.  Rev.,  No.  11,  p.371. 

1107.  Windsor.  Tb.,  A  new, operation  for  cataract.     Ibid.  p.  251. 

1108.  Quaglino,  On  scleronyxis.     Ibid.  No.  12.  p.  371. 

1109.  Little.  Cases  of  flap  extraction,  etc.    Ibid,  p.  398. 

1110.  Williams,  II.  AV.,  Remarks  on  tbe  use  of  suture  to  close  tbe  corneal 

■wound  after  removal  of  cataract  by  flap  extraction.     Opth.  Hosp. 
Rep.,  \I.  p.  28. 

1111.  Businelli.  Caduta  del  nucleo  del  cristallino  nella  camera  anteriore 

sette  anni  dopo  I'operatione  di  cataratta   per  abassamento.   etc. 
Giorno  d'Oftal.  Ital..  X.  p.  153. 

1112.  Liebeich.   Du  diagnostic  de  la  cataracte  et  de  I'appreciation  des 

methodes  operatoires  applicables  a  ses  differentes  formes.    Nou- 
veau  Diction,  de  Med.,  VI;  Ann.  d'Oc.  LVIII.  p.  103. 

1113.  Pires,  De  I'operation  de  la  cataracte  par  extraction  lineaire  sderot- 

icale.    These,  de  Paris,  in  8o,  p.  86. 

1114.  Knapp.  Bericht  uber  hundert  staarextractionen  nach  der  neucn  v. 

Graefe'schen   mcthode   ausgcfulirt.      An-h.    f.    Opth.,    XIII.   A.    1, 
p.   85. 

1115.  Weber,  A..   Die  uormale  linsenentbindung  der  modiflcirten  linear 

extraction  geAvidmet.     Ibid,  p.  540. 

1116.  Bergmann.    Ueber  entfernung  des   giauen   staais    mit   der   kapsei. 

Ibid.  XIII.  A.  2,  p.  383. 

1117.  Graefe.    v..   Noli/   uber  die   linsenentbindung  bei   der  modificirtea 

linear   extraction    und    vereinzelte  bemerkungen    uber    das    ver- 
fahreii.      Il)id.    p.    .".49. 


467 

1867.  ins.  K.-iinpf,  'rrauiuati.scbe  cataract*'  mit  fremdon  korpcr  in  dcr  liuse. 

Oestcir.  Zoitschr.  f.  Pract.  Ilcilk.,  No.  9. 

1119.  Kuchler,  Ueber  die  qnerextraction  des  staars.  Memorabllien,  XII,  1. 

1120.  Magni,    I>e   la    cataractc.   son   diagnostic  et  son   traitement.     Rlv. 

Clin.,  VI,  2. 

1121.  Wells.   Soelbei-fi.    Lt'ctun-s  on  cataract  and  the  modern  operation 

for  its  treatment.     .Med.  Times  et  Gaz.,  23  et  30  March. 

1122.  Watson,  Spenser,  Cas  de  cataraete  traumatique.     Ibid,  11  Mai. 

1123.  Iloerinfr,  F..  Die  modifircte  Graefe'sche  linearextraction.    Wurtem- 

bi'rg  ]Med.  Corresp.,  B.  1,  No.  24. 

1124.  Leiidiger-Formentel,  Cataraete  donble  chez  un  enfant  de  4  ans,  e  tc. 

Union  Med.,  No.  66. 

1125.  Meyer.  Ed.,  Du  noiiveau  ,procede  de  M.  de  Graefe  pour  I'extraction 

de  la  cataraete.    Ibid,  No.  99,  et  101. 
112G.  Terson,  De  la  cataraete.    Analyze  critique  et  indications  des  anciens 
et  nouveaux  precedes  operatoires.     Toulouse,  in  8o,  p.  79. 

1868.  1127.  Ilasner,  d'Artlia,  Dir  neue  phase  der  staaroperation.    Prag.,  in  8o, 

p.  15. 
112S.  Graefe,   v..   Ueber  v.    Ilasner's   kritik   der  linejirextraction.     Klin. 
Monatsbl..  VI.  p.  1. 

1129.  Ritter,  Anatoniie  du  cristallin.     Wecker,  Traite  des  ^laladies  des 

Yeux,  2  e  d..  II,  p.  1. 

1130.  Mauthner,  liClirbuch  der  Opthalmologie.     Wien. 

1131.  Schumann,     Ueber    den     mechanismus     der     accommodation     des 

menschlichen  auges.     Dresden. 

1132.  Coccius,   Der  mechanismus  der  accommodation  des   menschlichen 

Auges.     Leipzig. 

1133.  Rothmund,  Ueber  c.-itaracten  in  verbindung  mlfc  einer  eigenthum- 

lichen  hautdegeneration.    A.  f.  O.,  XIV,  1.  p.  1.59. 

1134.  Knapp,  Bericht  uber  ein  Ilundert  staaroperation,  etc.     Ibid,  p.  285. 

1135.  Foucher.  Lecons  sur  la  cataraete,  in  8o,  p.  287. 

1136.  Kuchler.   Die  qnerextraction  des  grauen  staars  der  erwachsenen. 

Erlangen,  in  8o.  p.  .•>7. 

1137.  Wolfe,  J.  R.,  On  imiirnvcd  metliods  of  extraction  of  the  cataract. 

I>ancet,  11  April. 

11.38.  Weclcer,  Des  nouveaux  iJi-ocedes  operatoires  de  la  cataraete;  para- 

lete  et  criti(iue.    Ann.   d'Oc,   LIX.   Mars  et  Avril.    Paris,   in  8o, 
p.  49. 

11.39.  Gnu'fe.  A.  v..  Uel)er  das  verfahren  des  peripheren  linearschnittes. 

A.  f.  ()..  XIA'.  .'!.  p.  10(i.    ISCS. 

1140.  Ileymann.  Velnn-  liuearextra<tioii.     Klin.  :donatshl..  VI.  326. 

1141.  Hoering.  Ueber  linearextraction.     Ibid,  331. 

1142.  Mannhardt.  Cataract  operation.     A.  f.  ()..  XIV.  3,  p.  26. 

1143.  Milliot,  Ueber  regeneration  dei-  linsc.    .Tourn.  de  Brux.,  XLVII.  Dec. 


468 

1868.    1144.   Siclit'l.  llistor.  iioliz  uIkt  dh'  opiTation  il.'s  jiraueu  staars  durch  die 
inetbode  dfs  aussaugens  od.  adsi»iration.     A.  f.  O..  XIV,  3,  p.  1. 

1145.  Tavignot,   t'eber  die    behandlunu;    der  cataracte    ohne    operation. 

Journ.  de  Bnix.,  XLYII.     D»k-. 

1146.  Taylor.   Cli.,   Ueber  cataract   extract  ion.      Brit.    .Med.  .Tourn.,   Nov. 

et  Dec. 
1S69.     1147.     Blessig.  Kericlit  ul)er  die  in  den  .laliren.  1.S64-68.  ausgefulirtcn  staar 
operationeu.    Petersb.  Med.  Zeitschr.,  XY.  3,  p.  145. 

1148.  Tavignot,  Pliospliorirtes  oel  gegen  cataract.     Presse  Med.,  XXI,  3, 

p.   26. 

1149.  Turner,  Cataract  uiit  complicationeu  l)ei  der  operation.    Pliiladelph, 

Med.  and  Surgie.  Reporter,  XX,  4,  p.  61. 

1150.  Ullersperger,  Spontane  eilung  einer  cataract.     Wieu.  Med.  Presse, 

IX,  48. 

1151.  Wagner,  Fremdkorper  in  der  linse.  Klin.  Monatsbl.,  VI.  p.  15. 

1152.  Collmann,  Beiderseitige  linsenverschiebung  durch  aussere  Gewalt. 

Ibid,  VII,  p.  48. 

1153.  Davis,  Dislocation  der  krystallinse.    St.  Louis  Med.  et  Surg.  .Tourn,, 

VI,  p.  38. 
11.54.  Noyej§,  Henry,  Operation  l)ei  verscbliessung  der  pupille  nach  cata- 
ractoperatlon.  O.  H.  M.,  VI,  p.  209. 

1155.  Taylor,  Further  observations  upon  an  improved  method  of  e  xtract 

ing  in  cases  of  cataract.     O.  H.  R.,  VI,  p.  197. 

1156.  Dantone,   Beitrage  zur  extraction   des   grauen   staars.      Erlangen, 

Enke. 

1157.  Galezowski,  Ueber  die  operation  der  cataract.    Gaz.  des  Hop.,  p.  86. 
1157a.  Xoyes,    Ueber  die   modificirte  lienarextrac^ion.     Transact,   of   the 

Americ.   Opthalm.   Society,  p.  28. 

1158.  Iwanoff,   Befund  eines  extrahirten  auges.     In:   Sympathische  Ge- 

sichtsstorungen  v.  Mooren.     Berlin,  p.  168. 

1159. ,  Anatomische  befunde  an  reclinirten  und  extrahirten  augen. 

In:    Beitrage  zur  ablosung  des  glaskorpers.     A.  f.  O.,  XV,  2,  pp. 
35,  38,  39,  41,  45. 

1100.  Gouvea,  Ueber  entstehung  der  glaskorperlosuug  nach  glaskorper- 

verlust.     A.  f.  O.,  XV,  1,  p.  244. 
1160a.  Horing.  Rejxinirte  luxation  der  linse.     Zehender's  Monatsblatter. 

1869. 
1160b.  Meyer,  Eduard.  Uelier  luxatio  leutis.     Ibidem. 
1161.  Strieker,  W.,  Zur  geschiclite  der  augeuheilkuude.     A'irchow's  Arch., 

XLVII.  p.  519. 
]1(;2.  Williams,  Ueber  cataractoperalion  bei  erwachsenen.     Transact,  of 

tlie  Amei.  Opth.  Soc,  p.  30. 
11(J3.  Barbour,  Cataracte.  Philade'ph.  Med.  and  Surg.  Reporter,  XXI,  231. 
1164.  IlirscI),  Kin  Avoi-t  zur  gescliichte  dei-  cataractoperationen  im  alter- 

tlmin.      Klin.    .Moiialsl.l.,   VII.   ]>.  2S'_'. 


469 

1869.     IKm.   KiiMpi).   St:iiin>iK'r:ili()iH'ii   ii.-n-h  dcr  iH-riplH-i-liiif.-ircn  oxi motion.    A. 
f.  A.,  u.  O.,  I,  1,  V.  44. 
HOG.  Noyt's.  Linseuluxatlon  in  dm  jil;isl<(iiiitr  luid  daiauf  in  die  vordere 
Kammer.     Ibid,  p.  ir.4. 

1167.  Reuss  u.  Woinow.    I'i'Iht  corneal-astifrinatisnnis   nacli   staaropera- 

tionen.    Wien..  Braunuillcr. 

1168.  Williams,  Ueber  staarcxtraction.     A.  f.  A.  u.  ().,  I.  1,  p.  91. 

1169.  Stophan.  Weitere  erfahruugeu  und  Studien  der  Jahre,  1867-69. 

1170.  Wolfo.  Tebor  cataractoxtraction.     Olasfiow  Med.  Jonrn..  S.  II,  1, 

p.  82. 

1171.  Monte.  Micliele  del.,  Feber  operation  <l(>s  liartcn  staars  durch  ex- 

traction. Morgagni,  XI,  p.  824. 

1172.  Noyes,  Cataraetmesser.    Transact,  of  tlie  Anier.  Optb.  Soc,  p.  51. 

1173.  Oglesby,  Entfernung  der  ganzen  iris  bei  einer  staaroperation.     O. 

II.  R..  YI,  p.  269. 

1174.  Williams.  Remarks  on  the  use  of  the  suture  to  close  the  corneal 

wound  after  removal  of  the  cataract  by  flap  extraction.    O.  H.  R., 
VI,  p.  28. 
1174a.  Hutchinson,  Clinical  notes  on  pyramidaj  cataracts,  with  specula- 
tions as  to  their  cause.    O.  H.  R.,  VI,  p.  136. 
1870.    1175.  Perrin,  P\alle  von  cataract  bei  diabetikern.  Gaz.  des  Hop.,  p.  63  u.  70. 
1176.  Walton,  Haynes.  Vorlesungen  uber  cataract.    Med.  Times  e  t  Gaz., 

p.  15  u.  26. 
1177.Charteris.  Falle  von  staaroperationen.     (ilasgow  Med.  Journ.,  II,  3, 
p.  481. 

1178.  Coppee,  Doppelseitige  cataract  operirt  mittelst  der  modificirten  lin- 

earextraction.     Presse  Medic,  XXII,  14. 

1179.  Giraud-Teulon.  Ueber  staaroperationen.     Gaz.  des  Hop.,  p.  159. 

1180.  Graefe,  A.  v..  Feber  den  peripheren  linearschnitt.    Klin.  Monatsbl., 

VIII,  p.  1. 

1181.  Mourton,  Ueber  luxation  der  linse  unter  die  conjunctiva.    Recueil 

de  Mem.  de  Med.  Milit..  3  Serie,  XXIV,  p.  414. 

1182.  Zereissung  des  augapfels;  verlust  der  linse  und  iris;  erhaltung  des 

sehvermogens.     Rrit.  :Med.  .Tourn.,  p.  40. 

1183.  Stilling.  Aphorismus  uber  den  erfolg  der  neueren  staaroperations 

methoden.     Klin.  Monatsbl..  VIII,  p.  97. 

1184.  Taylor.  Ueber  staaroperation.     Lancet,   .\pril.   Brit.   Med.  .Tournal, 

March. 

1185.  Wilson,  Henry.  Ueber  extracliou  des  staars  dunh   (Jraefe's  peri- 

pliercn  linearsclmitt.     Dubl.  .Tourn..  XLIX.  May. 
1180.  Coccius.  und  Wilhelmi.  Die  Heilaustalt  fur  arnie  augeukranke  zu 

liCipzig  7AU-  /.('it  ihres  ."(•  jnlii'iucn  besiehens. 
1187.  Blodig.  Karl.  Feber  die  dislocation  der  linse.     Wien.  .Med.  Presse, 

XI.  44. 


470 

1870.  1188.  Thiry,    Ueber    die    modificirte    lint'nr.'xtration    dos    staars.    Presse 

Med.,  XXII,  4. 

1189.  Delagarde.  Philip  Cliilwfll.  lU'lun-  cataractextraetioneu.     St.  Bartli. 

Hosp.  Rep.,  \I,  p.  5<'. 

1190.  Forster,  Ueber  den  peripheren  liuearsclinitt  bei  staaroperation.    27. 

.Tahresbericht  der  schles.    Gesellscli.  fnr  Yaterl.  Cultur.,  p.  220. 

1191.  Ritter,  Fall  von  acuter  oataractbildnnfr.  Klin.  Monatsbl.,VIII,  p.  256. 

1192.  Stellwag.    von   Carion,    Lohrbnch    der   prakt.      Augenheilkunde.   4. 

Aufl. 

1871.  1193.  Knapp.    Ueber    staarextraetion.     Transactions    of    the    American 

Opthalmological  Society.    Seventh  Annual  Meeting.  July,  1870. 

1194.  Hasner,  Ueber  die  staarextraetion.     Prag.  Yierteljahrschr.      C.  X, 

p.  73. 

1195.  Knapp,  Ueber  knoclienbildung  im  auge.     A.  f.  A.,  u.  O..  II,  p.  133. 

1196.  Lindner,    Luxation   de   linse   zwischen   sclera   und    bindehautsack. 

Oesterr.  Zeitschr.  f.  Prakt.  Heilk..  XXIV,  2. 

1197.  Aub.  Beitrage  yaw  kenntniss  der  vorletzungen  des  auges  und  seiner 

umgebungen.     A.  f.  A.  u.  O.,  II,  1,  p.  2.">2. 

1198.  Berthold,  Cataracta  congenita  capsularis  posterior.     A.  f.  O.,  XVII. 

1,  p.  169. 

1199.  Canstatt,  v.,  Zur  operativen  heilung  des  grauen  staars,  nebst  Nach- 

schrift  von  Zehender.     Klin.  Monatsbl..  IX.  p.  1.31. 

1200.  Galezowski.  Ueber  ein  neues  verfahren  zur  cataractextraction.   Gaz. 

des  Hop.,  36. 

1201.  Naquard,  Etude  sur  les  luxations  du  cristallin.    These,  de  Paris. 

1202.  Iwanoff.  Glaskorper.     Strieker's  Gewebelehre.  p.  1071. 

1203.  Ba1)ucliin.  Linse.     Ibid.  p.  1030. 

1204.  Gussenbauer.  Ueber  die  heilung  per  ])rimain  intentionem.     Arch. 

f.  Chirurgie,  XII,  p.  791. 
1204a.  Guberboch,Studien  ubei-  die  feineren  vorgange  bei  der  wundheil- 

ung  per  primam  intentionem  an  der  cornea.    O.  Q.  Jj.  Hft.,  4. 
1204b.  Westlioff.  De  operatic  de  senile  cataract,    Utrecht.  " 

1205.  Schiess-(;emuseus.  Angel)orener  linsendefect.     Klin.  M<matsbl.,  IX. 

p.  99. 

1206.  .Teatfreson.  Uelu-r  beliandlnng  der  calaiacte.     Lancet,  II.  12. 

1207.  — ,  Case  of  congenital  in:ili)osition  of  tlu'  lens  in  each  eye.     O. 

H.  R.,  VII.  p.  186. 

1208.  Keller.   Karl,   1.  Fall   von  dislocation  der  linse  am   reehten  auge. 

2.  Ueber   v.    (Jraefe's   mt'tliodc   der   staaroperation.      Wien.    Med. 
Presse.  XT  I.  40. 

1209.  Oettingen,  G.  v.,  Die  optlialuiologisclic  Kliiiik  Doipats  in  den  ersten 

3  .Tahren  ihres  Bestehens.     Dori)at. 

1210.  Pagenstecher.   Hermann.  Ueber  calar.-ict   oiicnnion  oliiie  crofPnung 

der  kapsel.  Ann.  d'Oc,  LXVl.  i>.  12t;. 


47  X 

1871.  1211.   Perriii.   V.M-fahii'ii  /ur  z.'isl.iniim  dt-r  kai.s.I   l.ci  .Icr  cntarnotoptT- 

ation.    Giiz.  ties  Hop.,  p.  54:'. 

1212.  Taylor,    Ueber   cataractoperation    inittelst   ciues    sdmittcs    an    tier 

periplierie  der  iris  ohno  veiictzung  dor  pupille.    Lancet,  II,  19. 

1213.  Tweedy,  Ueber  eine  sit-htbare  streifuiig  der  normalen  krystallinse. 

Lancet,  II,  19. 

1214.  Critchett,  G.,  Ueber  behaiidluim  der  f-ataracte.  Tresse  Med..  XXIV, 

p.  60. 

1872.  1215.  Midler,  Heinrich,  Gesamelte  uud  hiuterlassene  sehrifteu  zur  anato- 

mie  und  Physiologie  des  Auges.  Bd. 

1216.  Berthold,  I'eber  verknocherung  der  krystallinse  des  nieuschliehen 

auges.     A.  f.  ().,  XVIII,  p.  104. 

1217.  Salomon.  Max.  Dir  kraukheiten  des  linsensysteras.     Braunschweig. 

1218.  Loring,  Eduard  G.,  Astigniat.    (ilas  fur  starrkranke,  nebst  bemerk- 

ungen  uber  die  statistik  des  sehvei-mogens  nach  cataractopera- 
tionen.  Transactions  of  the  American  Opth.  Society.  Eighth  An- 
nual Meeting.  .July.  1872. 

1219.  Liebreich,  Eine  neue  methode  der  cataractextraction.    Berlin.  1872. 

St.  Thomas  Hosp.  Rep.',  II.  p.  259. 

1220.  Milliot.  Benjamin.  Ueber  regeneration  der  krystallinse  bei  einigen 

saugetheiren.     .Tourn.  de  I'Anatomie  et  de  la  Phys.,  VIII,  1,  p.  1. 

1221.  Rothmund,  A.,  Die  neueren  methoden  der  staaroperation,  mitget- 

heilt  von  Berger.    Bhitter  fur  Heilwissenschaft,  III,  1  u.  2. 

1222.  Wolfe.  J.  P.,  Ueber  traumat.  cataracte  und  deren  operation.    Brit. 

Med.  .Tourn.,  .Tan.  u.  March. 

1223.  Coates,  Traumat.  cataracte.    Operation.     Lancet.  I.  23. 

1224.  Forster,  Accommodationsvermogen  bei  aphakie.     Ivlin.   Monatsbl., 

X,  p.  39. 

1225.  .Teaffreson,  Schichtstaar.     Iridectoniie.     Brit.  :Med.  .Tourn..  p.  612. 

1226.  Panus,  Ueber  cataractoperation.     Gaz.  des  Hop.,  p.  4,52. 

1227.  Taylor,    Bribosia,    Hansen.    Discussion    uber   sl:iaroperatiou.    Klin. 

Monatsbl..  X.  Sept. 

1228.  Wolfe,  Traumat.  cataract.     Ibidem. 

1229.  Cowell,  George.  Entzundung    des    uvealtractus    bei    vater    und    3 

Sohnen:  anfaugliche  affection  des  rechten  auges  bei  alien,  darauf 
folgende  affection  des  linken  auges  bei  2:  catai'actose  linse  in  4 
augen;  congenitale  citaract  bei  der  Mutter.  Opth.  Hosp.  Rep.. 
VII,  3,  p.  3.33. 

1230.  Harlan  George  C.  Xucleai-cntaracte.     Pliil.i.  Med.  Times.  II,  4.'^..  47. 

1231.  Jacobson,    Widerlegung    der   neiiesten   augritTe   gegen    v.    Graefe's 

linearextraction.     A.  f.  O.,  XVI II.  1.  p.  297. 

1232.  Streatfeild,  Ueber  die  vortheile  der  anweiidting  scharfer  li.-iken  bei 

der  cataractoperation.     Lancet.  II.  2. 
12.33.  Driver,  Bericht  uber  .50  staarextractiouen  nacli  der  A.  Weber'sc  hen 
methode.     .\.  f.  ()..   XVIII.  2.  p.  2<mi. 


472 

1872.    1234.  Fano.  Uebrr  ein  wenis  bekanutes  vorkomiiiiss  bei  der  cataractoper- 
ation  nach  der  "preussischen"  methode.    L'Union,  p.  146. 

1235.  (loodmann,  Cataract  operation  nach   Liebbreich's  neuer  methode. 

Phil.  Med.  Times,  III,  50. 

1236.  Jeaffrson.  Ueber  cataractextraction.     liancet,  li,  December. 

1237.  Lawson,  George,  Einheilung  eines  eisensplitters  in  die  linse,  extrac- 

tion derselben  niit  dem   freraden  korper.     Hilling.     Med.  Times 
and  Gaz..  p.  569. 

1238.  Watson,  W.  Spencer.  Ueber  lappenox traction  der  cataracte.     Lan- 

cet, 11,  p.  866. 

1239.  Anagnostakis,   Zur  geschichte  der  opthalraiatrischen  chirurgie  im 

Alterthum.    Gaz.  Hebd.,  No.  9. 

1240.  — — -.  Annual  report  of  the  Massachusetts  charitable  eye  and  ear 

infirmary,  1873.    Boston.     (Report  on  64  cataract  extractions  ac- 
cording to  the  method  of  von  Graefe,  by  Dr.  Hesket-Derby.) 

1241.  Baudry,  S.,  Des  principaux  procedes  d'extracfiou  de  la  cataracte. 

Parallelo  et  critique.     52  pp.    Paris.    A.  Parent.     Ann.  d'Oc,  70, 
p.  107. 

1242.  Boniver,  Use  of  phosphorous  in  cases  of  cataract.    Lancet.  II,  p.  735. 

1243.  Braun,  Gustav  (Moskau),  Ein  beitrag  zur  nachstaaroperation.   Klin. 

Monatshefte  f.  Augenh.,  p.  142. 

1244.  Brettauer,  Dimonstrazione  d'un  caso  di  cataratta  corticale  poste- 

riore.     Indettorina,  II.    Morgagni 

1245.  Bibrosia,  Modifications  a  apporter,  en  certains  circonstances,  a  I'op- 

eration  de  la  cataracte  par  extraction  lineaire.     Discussion  Con- 
gres  de  Londres.     Compterendu,  p.  41-46. 

1246.  Chassaignac,   Sur  les   divers   modes  d'extraction  de  la   cataracte. 

Societe  de  Chirurg.,  21  Mai.     Gaz.  des  Hop.,  p   667. 

1247.  Coert,  J.,  De  schijabare  accommodatie  bij  aphakic.    Dissei-t.  Inaug. 

Utrecht.     Bijbladen.  14  de  A'orslag.  Nederl.  Gasthuis  voor  ogli.i- 
ders,  p.  33-84. 

1248.  Critchett,  G.,  Einige  winke  fur  die  behandlung  nooh  nicht  opera- 

tionsreifer   staare.     Opth.    Ges.    Klin.    :Monatsbl.    f.   Augenh.,   ]i. 
458-467. 

1249. ,  Traitemont  des  cataractes  en  attendant   I'operation.     Ann. 

d'Ocul.,  70,  p.  101-168.     Discussion  uber  mit  beginnender  cataract 
sich  entwickelunde  myopie. 

1250.  Derl)y,  Hasket.  Bericht  uber  64  staaroperationeu  nach  der  methode 

von   Graefe.    ausgefuhrt   im    Massachusetts   Hospital.     Arch.    f. 
Augen-und  Ohrenhlk.,  III.  1.  p.  193-198. 

1251.  Derby,  On  the  importance  of  an  accurate  record  of  all  operations 

for  cataract,  and  the  results  of  the  same,  with  practical  sugges- 
tions.   Transact.  Amerlc.  Opth.  Soc,  p.  58-64. 

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1263.  P^larer,  Giulio.  Semplificazione  al  melodo  di  de  Graefe  della  estra- 

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1278.  Hasner,  v.,  Die  subconjunctival  extraction.    Vorlauflge  Mittheilung. 

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1283.  Jacob,  H.,  The  removal  of  cataract  by  solution,  especially  with  re- 

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Gazeta  Lekarska,  No.  'J*',. 
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1291.  Lebriin.  Nouvelle  metliodc  .rcxtraction  d.-  la  .atara.tc  par  un  pro- 

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1292.  Lefort,  Leon,  Snr  la  valeur  des  differentes  methodes  d'extractlon 

de  la  cataraete.    Soc.  de  Chir.,  30  Avril.    Gaz.  des  Hop.,  p.  565-581. 

1293.  Lindner,  Sigmund.  Ein  fall  von  linsendislocation  niit  vollstandiger 

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1295.  Logetschnikoff,  Ueber  die  von  ihm  im  Jahre,  1872  und  1873,  nach 

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traction  de  la  cataraete  par  incision  dite  lineaire  ou  a  petit  lam- 
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1300.  Monoyer,  Ueber  cataractoperation.   Soc.  de  Chir.   Gaz.  Hebd..  p.  157. 

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1305.  Perrin,  Maurice,  Des  divers  procedes  «roperali<»n  de  la  cataraete. 

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1306.  Robinski,  Recherches  sur  le  cristallin.    Congres  de  Londres.  Compte 

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1873.  3o07.  Roosa,  John,  Liebreich's  extraction  of  cataract.  Dislocation  of  lens 
and  failure  to  escape.  Reopening  of  wound  nine  days  after.  Ex- 
traction of  lens.    Good  result.    Trans.  Amer.  Opth..  p.  69,  70. 

1308.  Samelson,  ,T.,  Cas  d'aniridie  traumatique  avec  ai»haliie.     Congres  de 

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aire.   Discussion.    Congres  de  Londres.   Compte  Rendu,  p.  154-159. 

1314.  Taylor,  Ch.  Bell,  Methode  propre  a  empecher  le  prolapsus  de  I'iris 

apres  I'extraction  de  la  cataracte,  au  moyen  de  la  separation  de 
riris  de  son  insertion  peripherique,  au  lieu  de  I'ablation  d'un  seg- 
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1315.  ,   On  the  new  method  of  extracting  cataract  by  peripheral 

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1316. ,  Operations  of  cataract.    Lancet,  I,  January  4,  p.  31. 

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1319.  Trelat,  L'extraction  de  la  cataracte.  Soc.  de  Chir..  30  Avril. 
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1321.  .  Quelques  considerations  sur  les  precedes  de  I'extraction  de 

la  cataracte,  et  une  nouvelle  methode  de  pratiquer  cette  opera- 
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1329.  -.  AVilson,  II.,  Des  aiguilles  pour  praticiuer  la  suture  apres  I'ex- 

traction  de  la  cataracte.  Congres  de  Londres.  Compte  Rendu, 
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1330.  Wilson,  H.,  Das  Brauu"sche  verfalireu  ziu-  (iperatiou  des  naclistaars. 

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1332.  Wolfe.    Sur   la   cataracte    traumatique.      Discussion.      Congres    de 

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1333.  Zeliender,W..  Kurzer  bericlit  uber  die  neuesten  vervollkomnmungs- 

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1340.  Ayres,  C.  S.,  Case  of  pyramidal  cataract  not  following  opthalmia 

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1341.  Agnew.  C.  R.,  A  contribution  to  the  statistics  of  cataract  extrac- 

tion of  1118  recent  cases.    P.  192. 

1342.  Adamink.  E.,  Zur  frage  uber  die  gultigkeit  der  cataract-extractions- 

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1343.  Becker,  Otto,  Atlas  der  patholog.     Topographic  des  Auges.  p.  241. 
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1348.  Andre,  Jjuxation  sous-conjuuctlvale  du  cristallin  sens  traumatisiue. 

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1349.  Cliauvel,  J.,  Note  pour  servir  a  I'histoire  de  la  cataracte  centrale  et 

acquise.    Arch.  Gen.  de  Med.,  p.  415-483. 

1350.  Classen,  A.,  Ueber  die  besf^  methode  der  eataractextraction.     S. 

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1351.  Calhoun,  A.  W.,  Report  of  77  operations  for  cataract.    Atlanta  Med- 

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1352.  Cywinski,     Kritik    der    Liebreich'schen    staaroperations-methode. 

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1353.  Coste,  Un  mot  sur  les  derniers  procedes  d'extraction  lineaire  de 

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1354.  Camuset,  GtH)rges.  Operation  de  la  cataracte  par  le  precede  fran- 

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1355.  Coppez,    Cliuique    opthalmologique    de    I'operation    de    cataracte. 

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1356.  Castorani,    Raphael,    Memoire    sur    I'extraction    lineaire    externe, 

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1357.  Cai-ter,  R.,  Brudenell,  Mr.  Bader's  "new  cataract  knife.     Lancet, 

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1358.  Chisolm,  Julian  J.,  Opthalmic  and  aural  surgery  reports.    Richmond 

and  Louisville  Medical  Journal.  January.  1873.    Ann.  d'Ocul.,  71, 
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1359.  Durand,  Alphonse,  Essai  sur  les  cataractes  leuticulaires  spontanees 

de  I'eufance.     These,  de  Paris. 

1360.  Demazure,  Essai  sur  la  cataracte.     Those,  de  Paris.     Nr.,  289. 

1361.  Derby,  Hasket,  Report  on  66  cataract  extractions,  being  those  done 

by  the  methods  of  von  Graefe  and  Liebreich.    S.  Oben.,  p.  192. 

1362.  Del  Toro,  Comparison  entre  la  keratotomle  lineaire.    Cron.  Opthalm. 

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Med.  Journ.,  I,  p.  325. 

2332.  Martin,  Maturation  artificielles  de  la  cataracte.    Journ.  de  Med.  de 

Bordeaux,  1885-86. 

2333.  Moeller,  Causistische  mittheilungen  uber  das  vorkommen  und  die 

operative- behandlung  des  grauen  staars  beim  hunde.     Zeit.  fur 
Vergl.  Augenheilkunde,  p.  138. 

2334.  Nettleship,  Traumatic  hemorrhage  behind  the  lens.     Opth.  Hosp. 

Reports,  XI,  1,  p.  62. 

2335.  ,  Neuralgia  in  cataractous  eyes.     Opth.  Hosp.  Reports,  XI,  1, 

p.  57. 

2336.  ,Spontanem   disappearance   of   diabetic   cataract.     Trans,    of 

Opth.  Soc.  of  United  Kingdom,  p.  107. 

2337.  Noyes,  Death  of  a  patient  under  extraction  of  hard  cataract.   Opth. 

Society. 

2338.  Mobius,  Uber  die  Foerstor'schen  iridectomie  maturans  zur  kunst- 

liche  reifung  immature  cataracte.    Journ.  Diss.  Kiel. 

2339.  Perrin,  Operation  de  la  cataracte.    Prog.  Med. 

2340.  Panas,  Dos  dernier  progres  realises  dans  operation  de  la  cataracte 

par  extraction. 
2341. ,  Bulletin  de  I'Academie  de  Medicine.    Seance  du  Jar.,  57, 1886. 

2342.  Power,  Case  of  black  cataract. 

2343.  Randall,  B.,  A  case  of  subluxation  of  the  lens,  with  double  rupture 

of  the  choroid.    Trans,  of  the  Amer.  Opth.  Society. 


523 
1880.     2344.  ,  A  case  of  multiple  rupture  of  the  eyeball,  with  partial  dis- 
location of  the  lens.    Trans,  of  the  Amer.  Opth.  Society. 

2345.  Robinowitch,  VAn  fall  von  ectoiisie  der  linse  mit  luxation  derselbo 

in  die  vodere  kammer.     Wjestnik  Opth..  No.  1. 

2346.  Rothziegel,  Uber  die  coincidence  von  cataract  >ind  nephritis  allg. 

Wiener  Med.  Zeitung,  188G,  No.  30. 

2347.  Rodzewitch,  Bericht  uber  das  crste  hundert  nach  von  Graefe  meth- 

ode  extrahirte  staare.    Wjestnik  Opth.,  1886,  No.  4. 

2348.  Reynolds,  Bandage  after  operation.     Med.  Record,  August. 

2349.  Rampoli,  I>ussazizone  spontanea  della  lente  cristallina  della  camera 

anteriore.     Annal.  di  Ottalm..  XV,  2-3,  p.  179. 

2350.  Rothmund,  T^ber  die  gegenwartige  nachbehandlung  der  staar  oper- 

ation.   Munchener  Med.  Woch.,  1886,  No.  19. 

2351.  Renton.  Note  on  the  value  of  corrosive  sublimate  solutions  in  opth. 

operation.     British  Medical  Journal.  No.  1340. 

2352.  Renard,  H.,  De  la  valeur  de  riridectoniie  dans  I'extraction  de  la 

cataracte  au  point  de  vue  des  resultats  de  I'operation;  contribution 

e  I'etude  comparee  des  precedes  de  v.  Graefe  et  de  Daviel.   These. 

Nancy. 
2.353.  Schoen,  Uber  die  Genese  der  aegnastinellen  cataract  durch  uher- 

anstorengung  der  ace.    Graefe  Arch.,  Vol.  XXXII,  B.  3. 
2354. .Zonula  und  grenzhaut  des  glaskorpers.     Graefe  Arch.,  Vol. 

XXXII,  B.  2,  p.  149. 

2355.  Stellwag,  Neue  abhandluug  aus  dem  gebiete  der  praktische  Augen- 

heilkunde.    Wien. 

2356.  Staderini,  Zwei  falle  von  zehr  seltener  angeborener  affection  der 

linse  und  der  zonula.    Annali  di  Ottalmologia  del  Prof.  Quaglino, 
1885,  Fas.  5  and  6. 
2.357.  Schweigger.    Staar    und    nachstaar    operationen.     Versammelung 
Deutscher  Natur.  Forscher,  Sept.,  1886.    Centralblatt  fur  Augen., 
p.  282. 

2358.  Szili,  A.,  Einige  bemerkungen  zur  erythropsie  frage.     Zehender's 

Klin.  Monatsblatter.    July. 

2359.  Strawbridge,  H.  G.,  Cataract  extraction:  263  cases  and  discussion. 

Twenty-second  Annual  Report  of  the  Amer.  Opth.  Society,  July 
21  and  22,  1886. 

2360.  Starkey,  H.  M.,  Three  cases  of  congenital  ectopia  lentis.     Chicago 

Society  of  Opth.,  December.  1886. 

2361.  Ayres,  S.  C,  Cataracta  pyramidalis.     Amer.  Journal  of  Opth..  1886. 

No.  1. 

2362.  Story,  Zonular  cataract  and  dental  malformations.     Opth.  Review. 

p.  354. 
236.3.  Sulzen,  In  vivo  sichbare  sternfigur  in  der  vodern  corticales  bei  zonu- 
la zonularis.  ctf.     Zehender's  Klin.  Monatsblatt.  p.  99. 


524 

188(i.     2304.   St;i(lcriiii,  Kiir  rjisi  di  i':n-issiniii  affox/JoiH'  luoi-bosii  dolla  loute  cris- 
talliiia  (■  (hi  siio  l.'.i^ainciito.     Aininal.  di  ()i)tli.,  XIV,  5-(>. 
2.305.   Spalding.  Kadical  cliaiiucs  in  Uk-  aftii-  ti-catmont  of  cataract.    Brit. 

]Mccl.  Journal,  Novouiber. 
2366.  Story,  Dental  malformations  and  zonula  cataracts.     The  Opthalmia 

Review,  October.  1880. 
2.367.  Sprimon,  ]Meclycyua.  1880,  S.  170. 

2368.  Telnekinu,  De  la  capsulotomie.    Annales  d"Oculisti<iue.  Tom.  XCV, 

1,  et  livraisons,  1886.     .Janv.,  Fevr. 

2369.  ,  De  la  capsulotomie.     Ann.  d'Oculistique,  XCV,  p.  43. 

2370.  Tyrman,  J.,  Ein  beitrage  zur  lehve  von  der  erythropsie.     Deutsche 

Med.  Zeitung,  No.  12. 

2371.  Uhle.    Fngewohnliches   selivermogen   eines   operirteru   auges.      Ze- 

.  bender's  Klin.  Monatsblatt,  p.  431. 

2372.  Vachez,  De  la  operation  de  la  cataracte.     Graefe  Hebd.  de  Med.  et 

de  Chir.     Avril. 

2373.  Reuss,  V.,  Die  operation  and  der  Second  Wiener  Kliuili,   1884-85. 

Wiener  Med.  Presse,  No.  49. 

2374.  Warlomont,  Le  extraction  de  la  cataracte.     Vingt-cingt  and  de  son 

histoire.  L'extraction  de  la  cataracte.  Vingt-cingt  de  son  histoire. 
Annales  de  Oculistique,  Tom.  XCV,  1,  et  2  livraisons,  1886.  .Tanv. 
Fevr. 

2375.  Webster,  50  cases  of  cataract  extraction.    New  York  Med.  Monthly. 
2.376. ,  Removal  of  a  piece  of  steel  from  t  he  crystalline  lens.     New 

York  Medical  Monthly. 

2377.  WickerkieWicz.  Irrigation  of  anterior  chamber  in  cataract  extrac- 
tion.    Congress  de  la  Societe  Francaise  d'Opth.    May,  1886. 

2.378.  Lange,  O.,  Nachtrage  zu  einem  falle  von  spontanea  aufhelung 
elner  cataractoseu  linse.     Graefe  Arch.,  Vol.  XXXII.  B.  4. 

2.370.  Green,  R.  L.,  Cataract.  St.  Louis  Med.  and  Surg.  .lourn..  No.  2,  p.  81. 

2.380.  Du.iardin.  eDux  cataractes  molles  opei-a  l'asi)iration.  .loiu-nal  de 
Sciences  Med.  de  Lille,  1886.     Aout. 

2381.  Gimning,  Sur  la  maturation  de  la  cataracte.  Ann.  dUc",  X('V.  p.  226. 
1887.  2.382.  Ayres.  S.  C,  After  treatment  of  cataract  patients.  The  -Vmerican 
Journal  of  Opthalmology.    January. 

2.383.  Abadie.  Ch.,  Des  precedes  actuels  d'extraction  de  la  cataracte. 
Progres  Medical,  March  26. 

2384.  Baker,  A.  R.,  A  further  report  of  extractions  of  senile  cataract. 

The  American  Journal  of  Opthalmology.    January. 

2385.  Berlin.   Staar  operationen  by  Thieren.     VII   Vergammelung  Opth. 

Gesellschaft,  September,  1887. 
2.386.  Bull,  C.  S.,    Simple    extraction    of    cat.-uact    Avitliout    iridectomie. 

Twenty-third  meeting  of  American  Optli.  Soiiety,  1887. 
2387.  Borthen.    Cataract   extraction    med.     Three    instrumenten.      Norsk 

Mag.     Marz. 


525 

1887.     2388. ,   Om  for  beredolsorno  till  katarakt  opcrationer  or  iridekto- 

iiiier  of  om   efter  behandlinsen  ofter  disse  operatloner.     Nork. 
Mag.    May. 

2389.  Burnett.   S.,   R(Miiarks  on   cataract   extracliou.      Amer.   M(!d.   Apoc. 

April. 

2390.  Bettnian.  Bocriic.  Arlilicial  ripcniiij;  i>f  cataracts.    Journal  of  Amer. 

Med.  Apoc.    December  3,  1887. 

2391.  Beveriui,  De  I'enclavenient  de  IMris  de  la  crystalloido  apres  I'oper- 

ation  de  la  cataracte  par  I'extraction  liueairo  combinee  a  I'lridec- 
tomie.     These,  de  Paris.  1887. 

2392.  Boe,  Recherclics  cxporiuuMitalos  pour  servir  a  I'etude  de  la  cata- 

racte trauniati(iue.     Arch.  d'Opth.,  VII,  3.  p.  193. 

2393.  Besselin.   O.,   Eln  fall   von  extrahirtem   und  microscopisch   unter- 

suchtem    schichtstaar  cines   erwachsenen.      Arch.    f.    Augenhell., 
XVIII.  1,  S.  71. 

2394.  Bass,  Uber  staar  erythropsie.     Klin.  Monatsblatt,  Bd.  XXV,  S.  453. 

2395.  Bogaiewzki,  Kurzer  ben-icht  uber  173  staar  operationen  im  Land- 

krankenhause  zu  krementschug.  Wjestnik  Opth.,  1887,  IV,  6,  S.541. 

2396.  Alt,  Adolph.  Rome  remarks  on  congenital  cataracts.    Amer.  .Toumal 

of  Opth..  .Tune. 

2397.  Chodin.   Auswashung  der  vodern   karamer  bei  staar  operationen. 

Congress  Russicher  Aerzte  in  Moskau.     January,  1887. 
2398. .  Uber  thermometrie  bei  Augen  operationen.     Congress  Rus- 
sicher Aerzte  in  Moskau.     January.  1887. 

2399.  Chisholm,  J.  J..  After  treatment  of  cataract  extraction.    The  revo- 

lution in  the  after  treatment  of  cataract.     Amer.  Journ.  of  Opth. 
June. 

2400.  Coleman,  J.  E.,  Use  of  galvanic  current  in  the  treatment  of  certain 

forms  of  cataract.    Chicago  Society  of  Opth.  and  Otology.    June. 

2401.  Collins,  Fuachen.  Statistics  of  cataract  operations  before  and  after 

the  introduction  of  cocaine.    Opth.  Hosp.  Reports.  XI,  3,  p.  338. 

2402.  Classen.  Uber  eln  eigenthumliche  methode  der  cataract  extraction. 

Munchener  Med.  Woclionschrift.  1887.  No.  46,  S.  903. 

2403.  Dor,  Napthalin  cataract.     Congress  Opth.     Mai.     Bulletin  et  Me- 

moires  de  la  Societe  Francaise  d'Opthal.,  p.  150. 

2404.  ,  De  la  production  artificielle  de  la  cataracte  par  la  napthaline. 

Rev.  General  d'Opthal.,  VI,  1,  p.  1. 

2405.  Deutshman.   Patliologisch-anatomische  untersuchungen  augen  von 

diabetikern,   nebst  beuierkungen   uber  die  pathogenese   der  dia- 
betischen  cataract.     Graefe.  XXXIII.  B.  2. 

2406.  — - — ,  Pathogenese  der  diabetischen  cataract.  Graefe.  XXXIII,  B.2. 

2407.  Kasaurow,  Dr.  Uber  ein  vereinfachtes  methode  der  staar  extrac- 

tion.   Russicher  Congress  in  Moskau.    January,  1887. 

2408.  DeWecker,   De  l^xtraction  de  la  capsule  anterieure  dans  I'oper- 

ation  de  la  cataracte.     Congress  Opthal.     May.  1SS7. 


526 

1887.     2409.  Dobrowolsky,  W.,  Uber  die  uisacheu  der  ei-ythropgie.   Graefe  Arch., 
XXXIII,  B.  2. 

2410.  Evetsky,   Ch.   O.,   L'albiiuiimirie  et  la  cataracte.     Arch.   d'Opthal. 

Juillet,  Aout. 

2411.  Smith,  Frank  Tester.  Cataract  operations  in  New  York.    The  Amer. 

Journal  of  Opthal.    April. 

2412.  Fontan,  J.,  Sur  la  cataracte  poiutille  post-typhoidigne.    Revue  Gen- 

eral Opth.,  No.  4,  Avril. 

2413.  Foerster,  Uber  luxatio  lentis.     Eighth  Versammelung  Opth.  Oesell- 

schaft  zu  Heidelberg.    September,  1887. 

2414.  Galezowski.  Operation  de  la  cataracte.    Congress  Opthal.  Mai,  1887. 

2415.  ,  Choix  de  la  methode  operatoire  de  la  cataracta.    Revue  Gen- 
eral Opth.,  No.  5,  Mai;  No.  6,  Juin. 

2416.  ,  Choix  de  la  methode  operatoire  de  la  cataracta.     Recueil 

d'Opth.     Juillet,  Aout. 

2417.  — .  Du  meilleur  mode  operatoire  de  la  cataracte  moyens  d'eviter 

les  complications  statistique.    Recueil  d'Opth.    Juillet,  August. 

2418.  ,  Aniridie  traumatique  avec  luxation  du  cristallin;  disci sion; 

guerison.     Recueil  d'Opth.     July,  November. 

2419.  Gottschau,  Uber  die  entwickelung  geschichte  der  augen  linse.   Cen- 

tralblatt  Ref.,  p.  157. 

2420.  Grandelement,  M.  E.,  Indications  des  lavages  intraoculaires  apres 

I'extraction  de  la  cataract.     Annales  d'Oculistique,  XCVII,  1  et 
2  livr.    January,  February. 

2421.  Gayet,  Antisepsis  oculaire.    Rec.  d'Opth.,  No.  5. 

2422.  Hess,  C,  Berichte  uber  Nineteenth  Versammelung  der  Opthal.  Ge- 

sellschaft.     Heidelberg. 

2423.  ,   Napthalin   veranderung  im   kaninchen   auge  und   uber   die 

massage  cataract. 

2424.  Heule,   Entvs^ickelungs   geschichte   der  krystallinse   u.  s.  w.    Arch. 

fur  Microscop.  Ant,  B.  XX,  p.  418. 

2425.  ,  Uber   albuminurie   und   cataracte.     Russicher   Congress   in 

Moskau.     January,   1887. 

2426.  Lawford,  J.   B.,   Concussion  cataract;  two  cases.     Opth.  Review, 

1887.    Twenty-five  cases  of  luxation  of  the  lens.    The  Royal  Lon- 
don Hospital  Report.    January,  1887. 

2427.  Jesop,    W.,    Lamellar   cataract.      Opth.    Soc.    of   United    Kingdom, 

1886-87,  VII,  p.  171. 

2428.  Knapp,   Lenses  of  1,000  successive   extractions   with   iridectomie. 

Twenty-third  Meeting  of  American  Opth.  Society.    1887. 

2429.  Kipp,  Case  of  spontaneous  absorption  of  senile  cataract  without 

injury  to  the  capsule  of  the  lens;  restoration  of  excellent  vision. 
American  Journal  of  Opth.    June. 

2430.  Ijagner,  Case   of   Recklinghausen   in    Nineteenth    Opth.    Congress. 

Heidelberger. 


527 
18K7.     2431.  Ix?c,  On  the  extraction  of  soft  c:itjir:ift  by  injections.    Brit.  Med. 
Journal.    January. 

2432.  Mn?:nus,  Therepeautisclior  Monatsclirift.   October.    Ub;-r  einfln.'!  »le.s 

napthalin  auf  dem  sehorgau. 

2433.  Meyer,   Paul,   Die  spontane  aufsugnng  cataracta   senilis.     Graefe, 

XXXIII,  B.  1. 

2434.  Moeller,    Ca.suistisclio  niiltlu'iliiii;;    uber  das  vorkoniiueu    unci    die 

operative  behandlnng  des  .sranen  staars  l)eini  Ininde.     Zeitselirift 
fur  Augenlieillvunde. 

2435.  Mules,  Cataract  extraction.     .\  new  method  ol  treatinj;  an  old  com^ 

plication.     British  Medical  .loiiiii.il.     .inne  11. 
243(5.  Mathiossen.  Ludwig.  Beltrag  zur  dioptrie  der  krystallinse.    Berlin. 
Everbusch  Zeitschr.  fur  Verg.  Augenheilkunde. 

2437.  Mooren.  simple  method  of  extraction.    International  Med.  Cbngress, 

Washington,  D.  C.    September.  1887. 

2438.  ]\lanolesca,  Comapres  calanici  extraction  with  and  without  Iridec- 

tomie.     International    Med.    Congress.   Washington.    D.    C     Sep- 
tember, 1887. 

2439.  Montgomery,  W.  J.,  After  treatment  of  cataract  extraction.    Aiuer. 

Med.  Apo. 

2440.  McKeown,  Intra-capsular  injections  in  cataract  extraction.     Brit. 

Med.  Journal,  September  3. 

2441.  Mandelstamm.  Ein  fall  von  beiderseitger  spontaner  linsen  luxation. 

St.  Petersburg  Med.  Wochenschrift,  No.  16. 

2442.  Montagnon,  M.  P..  Luxation  lens.     Amer.  Journal  of  Opth.,  IV,  6, 

p.  157. 
'  2443.  McKeown,  Intra-capsular  injections  in  the  extraction  of  cataract 
British  Medical  Journal,  No.  1412,  p.  1589. 

2444.  Neese,  E.,  Uber  das  verhalten  des  epithels  bei  der  heilung  von  lin- 

ear und  lanzen  messer  wunden  in  der  hornhaut.     Graefe,  VoL 
XXXIII.  B.  1. 

2445.  Nieden,   Cataract  bilduug  bei   teleangiectatischer  ausdehnung  der 

capillaren  der  ganzen  gesichtshaut.     Centralblatt  f.  Prakt.  1887, 
S.  353. 
244G.  Pannas,  Etudes  sur  la  mitritiar  de  I'oeil  apres  des  experiences  faites 
avec  la  flourescine  et  la  napthalin.    Arch.  d'Opthal.    Mars,  Avril. 

2447.  Purtscher,  Neue  beitrage  zur  frage  der  erythropsie.   Arch.  f.  Augen- 

heilkunde, XVII,  p.  260. 

2448.  Peignon,  De  Textraction  de  la  capsule  anterieur  dans  Toperation  de 

la  cataracte.    Paris,  1887. 

2449.  Randolph,  R.  C,    Ein    beitrag    zur    nachbehandlung  von    cataract 

patienten.     Centralblatt  fur  Prakt.    Augen,  Mai. 

2450.  Rohmer,  Maturation  artificielle  de  la  cataracte.     Congress  Opthal. 

Mai.  1887. 


528 

1887    2451.  Raniiioli.   Maturation  artiliciolle  de  la  cataracte.     Congress  Opthl. 
Mai.  ST. 

2452.  E.  Aucora  inrticata  in  qualehe  caso  la  deprossione  della  catteratta. 

Annal  d'Optli.,  XV,  p.  423. 

2453.  .  Sulla  matura  infettiva  della  pauotalmite  ehetalora  conseque 

alia  ostrazione  della  cataratta.    Annal  d'Ottal.,  XV,  5-6. 

2454.  Randolph,  Ein  Beitrag  zur  Nachbehandlung  von  Cataract  patienten. 

Centralb.  f.  pr.  A. 
245.5.  Rheindorf,  J..  Zur  Staarop(M-ation.     Arch.  f.  Augenhoilkunde.  XVIII. 

S.  180. 
24.50.  Schlosser.  K..  Experiuientelli  Studie  uber  traumatiseher  kataract. 

Munchen,  87. 
2457.  Schocn.  Win..  Die  Accommodation  und  deren  folgen  Aetiologie  des 

Glauc.m  und  der  Alters  Cataract.    Graofe  Arch.,  XXXVIII,  B.  I.: 

also.  Arch,  fur  Augenheilkunde,  XVII. 
24.58.  Schirmer,  Experimentel  Studio  in  Reine  Linsen  Contusion.    Dissert. 

Inang.  Greifswald. 
2459.  Stolting,  Glaucom  nach   Linear  Bxt.     Graefe  Arch..  Vol.  XXXIII. 

B.  2. 

2400.  Stein.  Stanislaus.  Staar  (lurch  Tone  erzeught.    Centralblatt  f.  Augen- 

heilkunde; 1887.  .Ian.,  p.  6. 

2401.  Saurez.  Success  iiiimediat  et  insuccess  tardif  dans  operation  de  la 

cataracte.     Congress  Opthal.,  Mai,  87. 

2402.  Suarez  de  Mendozza,    Sur  la  success  immediat  et  I'iusuccess  tardif 

dans  operation  de  la  cataract(\    Revue  General  Optii..  :Mai. 

2463.  Schweigger,  Cataract  Extraction.  VII.  ^■(■rsnmnl(•Iung  Gesellschaft 
zu  Heidelberg;  Sept.,  87. 

2404.  Silex,  P.,  Bericht  uber  122  P]xtractionon  von  Altersstaar  mit  Eroff- 
nung  der  liinsenkapsel  durch  die  Kapselpincette.  Arch.  f.  Augen- 
heilkunde, XVII,  4. 

240.5.  Swanzy,  Intracapsular  injections  in  cataract  extractions.  British 
Mea.  Journal,  Sept.  17. 

2400.  Telzer,  Compendium  der  Augenheilkunde.  4.  Auflage.  S.  282. 

2407.  Thompson,  J.  L..  Congenital  and  spontaneous  displacement  of  the 

crystalline  lens.    American  Med.  Apoc. 

2408.  Vachez.  Du  lavage  de  la  chambre  anterieur.      Congress  Opthal.,  Mai. 

87. 

2409.  Valk,  Franc.  Report  of  four  operations  for  rfmoval  of  cataract  with- 

out an  iridectomie,  by  an  enliicly  new  method. 

2470.  Williams,  The  latest  pliases  of  cataract  extraction.  St.  Louis  Med. 
and  Surg.  Jour.,  No.  5,  p.  358.  The  gi-and  effect  of  cocaine  in  cat- 
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2171.  Zancoval-Terson,  Du  lava.go  de  la  chambre  antcritMir  apres  I'opera- 
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529 
18S7.    1^471^.   /chriKlci-,    W..    Cjilnnicl    i:\t.    'I'...l.    in    folti"     voii    Kclniiococciis   dor 
Wil/.     Klin.  .MoiKitsl.l.-iU.  X.W.  s.  :\\r>. 

2473.  .F:u-()lis(.ii.   .1.,    I'bor  cMlMnict   cxlriiclioii.       I  (('Ulsclii'     .M.-d.     Wochen- 

sohrill.  VIU,  No.  7S. 

2474.  Critclu'tt.  Dislocation  of  tlie  Iciis.     I'.iilisli  Med.  .I(.uni;il.  Jann.iiy. 

2475.  Kiilili.  Vi.T  I'':ill(>  von  I'^rylliropsi.-.     WJrstnik  Optli.,  IV.  :'.,  p.  2(19. 
247(5.   Sclidllcr.    'Auv    St:i;ir(.i'fr;il  ion.       r.rrlinci'    Klin.    Woc-lii'iisclififl.    87. 

No.  .•'.8. 
1888.   2477.   .Vbinro,     Do  r:intisc|.sis  oi   rnscpsis  (hins  oix-ratioii  dc  la  cataracte. 
Arch.  d'Opth..  .lau. 

2478.  Arniaiunac.  Xouvelle  iiincc  ponr  cxliacrn.n  dnii  lam  bccuin  de  cap- 

sido  anteriour  dans  ropi-iation  dc  la  c-atara<t.    Kef.  d'Optli..  No.  3, 
p.  177. 

2479.  Bcselin.  Eiu  Fall  von  c.xtraliirten  iind  niici-osfopischon  untersuchtem 

Schichstaar   eiuer   erwachseuen.      Arch.      f.     Ausenlieilkunde.    B, 
XVIII. 

2480.  Burcbardt.    Sdiichstaar   mil    nn.Licwolinliclicr   Zciflinnnjj:   der   Voder 

flache.     Indication  tin-  die  Ait  der  Operation.     Cbarite  Aunalen, 
1888. 

2481.  Ball.  Case  of  cataract  extraction,  witb  remarks  on  nse  of  cocaine. 

Med.  Reg..  IV,  21,  p.  485. 

2482.  C.  Yian.    Des  pro.ures  accomplis  dans  le  traitement:  cbirurgical  de 

la  cataracte  et  du  procede  de  elioix.     Recnel  d'Optli..  .Tan. 

2483.  ("bibret.  Infection  secondaire  de  I'oeil  npres  Toperation  de  la  cata- 

racte.    Rev.  General  d'Oiilli.,  \'II.  1..  p.  1- 

2484.  Cauldron,     Tranmatismu-  du  criiallin  nii   cas  de  contusion   simple. 

Rev.  General  d'Opth..  Xt).  12. 

2485.  Charrin  and  Roger,    Experinientel    Cataiaci.      Menthol).    Arch.   f. 

l»rakt.  Augenheilknnde,  Febry.,  1888;  p.  60. 

2486.  Dixti,  Die  Kunstliche  Reifung  der  Cataract.     Mailaud. 

2487.  Doyne,  A.peculiar  form  of  degeneration  of  the  lens.     Opth.  Society 

of  United  Kingdom;  Oct.,  88. 

2488.  Drake-Brockuian,    A    statistical    review    of  1,626  cases  of  cataract 

extraction.     Madras.  Oiithalmie  Review.  Nov. 

2489.  Dufonr.  Sur  la  one  rouge  on  I'enthropsie.     Mai. 

2490.  Deuot   Kin.    Uber    die     I >ilatatorecToinie     bei     Cataracta     mularis. 

Wjestnlk  Opth.,  Vol.  I. 

2491.  Derby.  H..  On  the  dangers  of  simple  extraction  of  cataract.     Boston 

Med.  and  Surgical  .loiirnal.  CXYIII,  8.  p.  189. 

2492.  Doyne,  A  peculiar  degeneration  of  the  lens.    Opth.  Soc,  Dec.  13. 

2493.  Eoliver,  Belt,  Bericht  uber  100  staaroperation.     Knapp  Arch..  Vol. 

XIX.  B.  2. 

2494.  Fuchs.  I'ber  traumatisclie.    Klinisclie  Woclienschrift.  Xo.  3  and  4. 

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530 

1888.    2496.  F.    Me^er,    Ein    Fall   von    Lonticouiis    iiosterior.      Arch,    fur   Prakt. 
Augenheilkiuulo;  Febry..  1888. 

2497.  Flenzal,  Discission  mit  dem  Lanzenmesser  bei  den  verschiedent-u 

Arten  von  Angeboreuer  Cataract.  Societe  Francaise  d'Opth., 
May  9,  1888. 

2498.  Freyer,  B.  E.,  Excessive  hemorrhage  of  several  hours'  duration  after 

cataract  extraction  (senile),  d  case).  American  .Tournal  of  Opth.. 
February. 

2499.  Fischer,  F.,  Bericht  uber  ein  acht  yuliriges  kind  mit  augeborener 

totaler  cataract  und  dessen  verhalten  wahrend  der  Ersten  Wochen 

2500.  G.  A.  Berry,  Note  on  an  instance  of  marked  hereditary  in  a  form  of 

nach  augelangtern  Sehen. 

cataract  developed  in  early  life.    The  Opthalmic  Review^,  Jany. 

2501.  Galezowski,   Extraction  des  cataractes  luxees.     Societe  Francaise 

d'Opth..  Mai  9,  1888. 

2502.  ,  Traitement  de  la  cataracte  luxee.    Recueil  d'Opth.,  Mai. 

2503.  Goldzieher,  W.,  Zwei  Falle  von  beiderseitiger  angeborener  cataract 

nebst  Bemerkungen  uber  das  Schenlerhen  Blindgeborener.  Wie- 
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2504.  Gayet,  Report  of  cataract  extraction.     Seventh  Internation  Opth. 

Congress,  Heidelberg;  August,  88. 
2505.  Gauita,    Proliferazioni  degli  epiteli  corneale  sull  iride  a  nella  pu- 
pilla  in  seguito  od  ablazione  di  cat.    Annal  d'Opth.,  2,  p.  145. 

2506.  Gad,  A.,  Bt  Tilfaelde  af  Resorptio  oataractae  senilis  intracapsularis. 

Wordisk  Opth.  Tidsskr,  4,  p.  262. 

2507.  Graefe,   A.,   Ein  vv^ort  fur  Beibehaltung  der  Iridectomie  bei   Ext. 

barter  Cataracte.    Graefe  Arch.,  XXXIV,  3,  p.  223. 

2508.  Hess,  Zur  Pathogenese  des  Micropthalmus.    Arch.  f.  Opth.,  XXXIV, 

B.  3. 
2509.  Resopnse  a'M.  Pr.  Panas  sur  la  cataracte  napthalinique.   Rev.  Gen- 
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2510.  — ,  Experimentelles  uber  Blitz  cataract.     Opth.  Congress,  1888; 

p.  14'/. 

2511.  Hirschberg,  Geschictliche  Bemerkungen  Noch  einmal  die  Staraus- 

ziehung  bei  den  Griechen.  Arch.  f.  Prak.  Augenheilkunde:  July. 
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2512.  ,    Zur    Wundbehandlnng    des     Starschnitts.       Berliner     Med. 

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2513.  — -,  Tropfen  bildung  bei  begiuuenden  staar.     Centralblatt,  p.  32L 

2514.  Hedeus,  Ectopic  lentis,  atrophischer  zonula.    Vior  fachsehen.     Ze- 

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2515.  Herman   Becker,   Ein  Fall  von   Mikroptlialmus   cungenitus   unilat- 

teralis  nebst  einigen  Bemerkungen  uber  die  vermuthliche  Aetiolo- 
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XXXIV,  B.  3. 


531 
1888.    2510.  Hosch.  Zur  Erbllchkeit  dos  fjrauen  staares.     Con-Bl.  of  Schwelzer 
Aerzte.,  XVIII,  No.  19,  p.  599. 

2517.  Jacobson,  J..  Sr.,  Von  Graefe's  Modlflrcte  Linear  Extraction  und  der 

Lappenscliuitt  nach  oinigen  Erfalirnnjr  a  us  dor  Zoit.    1854-1888. 
Giaefe  Arch.,  XXXIV,  B.  2. 

2518.  J.  Bejerrum,  Statlstik  uber  Inflammatorische  Falle  von  Cataract 

Extraction.    Arch.  f.  Augenheilkiuide,  p.  381. 

2519.  Jessop,   Symmetrical  rings  of  pigment  on  the  anterior  capsule  of 

lenses,  resulting  from  foetal  iritis.  Trans,  of  Opth.  Soc,  1887-1888, 
p.  126. 

2520.  Kniess.  Gruudriss  dor  Augonhcillcundc.  S.  282. 

2521.  Knapp,  Extraction  of  cataract  without  iridectomie.     N.  Y.  Medical 

Record,  Febry-  H-  1888.     (Arch.  f.  Aug.,  p.  S5i.     Also,  Arch,  fur 
Augonheilkunde,  Vol.  XIX,  T. 

2522.  ,   Simple  extraction  of  cataract.     Boston  Med.  and   Surgical 

Journal.  CXVIII,  No.  14. 

2523.  Knox.  Shaw.  Two  cases  of  dislocation  of  the  crystalline  lens.    Opth. 

Review,  No.  83. 

2524.  Lawford,  Pathological  Anat.  of  Lamellar    or    Zonu'ar     Cataract. 

Royal  Lond.  Opth.  Hospital  Reports.  Vol.  XII.  P.  II.  p.  184. 

2525.  Little.  David.  Operative  treatment  of  zonular  cataract.    British  Med. 

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2526.  Landesberg,   M.,   Zur  aetiologie  der  cataract  bildung.     Arch,   fur 

Prakt.  Augenheilkunde.    February.  1888. 

2527.  Laske,  Die  sescharfe  nach  cataracte  extraction.     In  Din.  Kiel. 

2528.  Magnus,   Hugo,    Linsenernahrung  und  lens   ertrubung.     Deutsche 

Med.  Wochenschrift,  No.  40. 

2529.  ,  Zur  Historische  Kentniss  der  Vodere  Kammer  Auswaschun- 

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2530.  ,Zur   Klinische   Kentniss   der   linsen   contusionen.      Deutsche 

Med.  Wochenschrift,  January  28,  No.  3. 

2531.  McKeown,  On  one  hundred  cases  of  cataract    mature  and  imma- 

ture, treated  by  intraocular  injections.     Brit.  Med.  Journal. 

2532. -,   Instrument  pour  les  injections  intraoculaire  dans  I'extrac- 

tion  de  la  cataracte.    Annal.  d'Oculistique,  XCIV,  p.  144. 

2533.  Norris,    Gordon,    Acutu  linsen   astygmatismus.      Arch,    fur   Prakt. 

Augen.,  August,  p.  2.34. 

2534.  Nicati,  Spontan  heilung  der  cataracte  senilis.     Academie  der  Wis- 

senshaft  zur  Paris.    May,  1888. 
2.535.  Becker,  Otto,  Die  Universitats  Augenklinik  in  Heidelberg.    Zwanzig 

Yahre  Klinischer  Thatigkeit./  Heidelberg. 
2536.  Motais,    Nach    staar    operatioii.      Societe  Francaise  d'Opth.     May 

9.  1888. 
25.37.  Pageustecher,  Herman.  Tiber  staar  oxtractione  mit  und  ohne  ent- 

fernung  der  kapsel.     Graefe.  XXXTV,  B.  2. 


532 

188S,     2538.   l';iii;is.  Catjirnct  cxlnK-tioii.     r.-iriscr  AcMdcini;'  der  Mcdicin.    Arch, 
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2539.  — .   Des  opiM-atione  dc  calaraclc  par  cxli'action  prati<nuH's  a  la 

clinique  de  THotol.  Dicii  dans  Ics  trnis  d(  riii(  res  amies  avoc  lav- 
age a  la  chambre  Jiiitcricur.     An-li.  d'Opth..  \1II.  1.  p.  G4. 

2540.  Proudfood,  A..  Excessive  lieniorrliagc  after  cataract  extraction  fone 

case).    October.  March. 

2541.  Pomeroy.  Kenioval  of  tlie  dislocated  l(Mis  witli  hidcni.     Ainer.  Jour. 

of  Opth..  No.  10. 

2542.  Carter,  R.  Brunadel.   Introduction  to  the  discussion  ou  the  treat- 

ment of  senile  cataract.    Brit.  Med.  Journal.  November  24. 

2543.  Rei.yel,   Zur  pathologie  der  sulicoiijnnct  ivnlen   linsen   luxation.      In 

Dis.  Munchen. 

2544.  Rodsewitch.  Rericht  nber  das  zweite  liundert  von  cataracte  extrac- 

tionen.    W.iestnik  Opth..  Vol.  III.  p.  24S. 

2545.  Schoen,  Die  ursache  des  grauen  staars.     Arch,  fiu'  Augenlieilkimde. 

XVII  and  XIX. 

2546.  Scliirnier.  Otto,  Experimentelle  studie  uber  die  P^oerster'sclie  matu- 

rati(jn  der  cataracte.     Graefe.  XXXIV.  R.  1. 

2547.  Snell,    Simon.    On   the   after   treatment   of   cataract.      British   Med. 

Journal. 
254S.  Schuabel.  Die  entwickelung  der  staar  operations  methoden  in  den 
letzen  20  yahren. 

2549.  Swanzy.    Intracapsular    injections  in  tlie    extraction  of    cataract. 

Brit.  Med.  Journal.  February  IS. 

2550.  Schweigger,  Zur  cataract  extraction.     Erweidernng  an  Prof.  .Jacob- 

son.     Greaefe  Arch..  XXXIV,  B.  3. 
2551. ,Die  Ruckkehr  zum  lappenschnitt.     Knapp  Sclnveigger  Arch.. 

B.  XVIII. 
2.5.52.  Steffan.  Ch.,  Ein  technik  des  peripheren  flachen  lappenschnitt.    Ze- 

hender's  Klinisclie  Monatsheft.     June. 
2553.  Scimenl.  Case  of  zonular  cataract.     Bolletino  d'Oculistica.  No.  8-9. 

Arch,   fur  Augenheilkunde,  p.  308. 

2.554.  Silex.  I'aul,  Zur  frage  der  accommodation  die  aphakischen  auges. 

Isnappacl!.  Vol.  XTX.   B.  1. 

2.555.  Sulzer.  I).  E..  Over  blijfselen  van  het  achterste  gedeelte  van  de  vaa 

IhoiKh'u  de  foetale  len  ka]isel  bi.j  eim  volwassene  aan  een  oog  met 
meinbrana  ])ui)illaris  i)erseverans  en  andere  out  wikkelings  anom- 
alien.  (Jeneeskundin  'rydscliiMft  voor  Nedeklandsch.  Iridie  Deel. 
XX VII.  At.  1. 

255«.  Tomatola,  lai.xatioii  of  lens  under  the  conjunctiva.  Bollt  tino  d'Ocu- 
lislic:i.  Xo.  VI.     Arcli.  fur  .\ugeiilieilkunde. 

25.57.  Treacher.  Collins.  Some  of  the  complications  after  extniction  of 
ca1:ir:icl.     Uo|':il  <>i)tli.   IIosp.   Kepoits,  .Fanuary. 


533 
18S8.     2558.   Vahule,  Kr.vllnopsif.     ("lini.|Uc  d'Oi.tli.  <1('  lii   F.-iculIc  dc  Bordeaux. 
Mars,  Avril. 

2559.  Vian,   Des   projrres  accoinijlis   dans   riraitciiiciil    cliinirKieal   de  la 

cataracto  rt   dii  proccde  dn  clinix.     Kcc  <r()plliMl..   No.   1.   p.  41; 
No.  2,  p.  92. 

2560.  Valude,  L'erythropsic.     Arch.  f.  Optb.,  VIII,  2,  p.  l.'JO.     St.  Louis 

Med.  and  Surgical  Journal. 
2561.Westhoff,  Erytbropsie  boi  aphaliie.  Centralblatt  fur  d. 

2562.  Webster,  David,  Extraction  of  a  partially  absorbed  calcareous  cata- 

ract.   N.  Y.  Med.  Record,  September  29,  188.S. 

2563.  Williams,   Hemorrhage  long  after  cataract  extraction.     St.   Louis 

Med.  and  Surgical  .lournal,  LIV,  2,  p.  106. 
2504. ,   Apparent  ossification  of  an  old  lens.     St.   Louis  Med.  and 

Surgical  Journal,  No.  3,  p.  178. 
25tJ5.  ,  Cocaine  and  loss  of  vitreous  in  cataract  extraction.    St.  Louis 

Med.  and  Surgical  Journal,  No.  4. 

2566.  .   Subluxation  of  both  lenses  by  separate  blows.     St.   Louis 

Med.  and  Surgical  Journal,  LV,  p.  36. 

2567.  Wielierlviewicz.   Einige  bemerkungen  uber  die  augenkammer  aus- 

waschung.     Seventh  Int.  Congress  Opth. 

2568.  Wickerkiewicz.  Bogdan,  Beitrag  zur  kentniss  der  Paris  tirende  pu- 

pilla  membrane.     Graefe  Arch.,  XXX IV,  M. 

2569.  Holtz,  F.  C,  Excessive  hemorrhage  after  cataract  extraction;  two 

cases.     American  Journal  of  Opth.     March. 

2570.  Little,  D.,  On  operative  treatment  of  zonular  cataract.    British  Med. 

Journal,  No.  1413,  p.  178. 

2571.  Arcoleo,   L'estrazione  della  capsula  anteriore  del  cristallino  nella 

operazione  della  cataratta.    Annal  d'Ottalm.,  XVII,  4. 

2572.  Czermak,  Uber  extraction  der  cataract  ohne  iridectomie  mit  naht 

der  Wunde.    Wiener  Klin.  Wochenschrift,  No.  29  and  30. 

2573.  Norsa,  TJn  cas  de  luzzazione  spontanea  della  lenta  cristalliue  nella 

camera  anterior.    BoUet  della  Soc.  Lancisiana  Roma. 

2574.  Gunn.  Growth  of  new  lens  fibres  after  spontaneous  absorption  of 

traumatic  cataract.     Trans,  of  Opth.  Soc.  1887-88.  S.  126. 
ISSlt.    2575.  A.   Wagenmanu,   Neubilduugen   von   glashautige   substanz   an   der 
linsen  kapsel,  etc.     Graefe  Arch.,  Vol.  XXXV,  B.  1. 
257(>.  Alfred  v.   Graefe,   Fortgesetzte  bericht  uber  die  mittelst  antisep- 
tische    wundehandlung    erzielte    erfolge    der    staaroperationen. 
Graefe  Arch.,  Vol.  XXXV,  B.  3. 

2577.  Abadie.  De  certaines  complications,  qui  survieiiiient  nuelques  jouss 

apres  I'operation  de  la  cataract.     Ann.  d'Oculistique,  Marz,  April. 

2578.  Baker,  A.  R.,  A   few  observations  on  the  etiology,  prognosis  and 

cure  of  incipient  cataract  without  o|)erative  interference.     Cleve- 
land Med.  Gazette.  July.  1889. 

2579.  DaGame.  A.,  Cataract  operation  witliout  iridec1onii.>.     British  Med. 

Journal.   No.   1507.   p.   1093. 


534 

1889.     2580.  Bnint'dell,    CaiteT,    Treatment    of   senile    cataract   and   discussion. 
British  Med.  Ap.  Opth.  Review,  September,  1888. 

2581.  Bribosia,  Avant  pendant  et  apres  I'extraction  de  la  cataracte.    Ann. 

d'Oculistiqiie.  January. 

2582.  Brettrenieux.  P.,  Une  modificMtion  du  couteau  a  cataracte.     Arch. 

d'Opthal.,  January,  1889. 

2583.  Baudon,  Note  sur  la  resultats  obtenus  dans  cent  quarente  opera- 

tions de  cataract.    July,  1871,  1888. 

2584.  Blanch  Aguilar,  Quelle  est  la  meilleure  inethode  d'extraction  de  la 

cataracte.    August,  1871.  1888. 

2585.  Hess,  Carl,  Beschreibung  des  auges  von  Talpa   Europea  imd  von 

Proteus  Auginens.    Graefe  Arch.,  Vol.  XXXV,  B.  3. 

2586.  Lee.  Chas.  G.,  Extraction  of  soft  cataract  by  intracapsular  injec- 

tion.    British  Med.  Journal,  March  30,  1889. 

2587.  Cereseto,  460  cataract  extractionen  von  Panas  ausgefuhrt.    Gazette 

Med.  di  Torno,  1888,  No.  14. 

2588.  Curatulo,   Exeprimente  uber  die  napthalin  cataract.     Ceutra'blatt 

fur  Augen,  p.  352. 

2589.  Kunn,  C.  G.,  Vererbung  des  schichtstaars  in  einer  familie.    Wiener 

Klin.  Wochenschrift,  No.  3. 

2590.  Curatulo,  Uber  die  durch  napthalin  erzeugte  cataract.     Lee  Mor- 

gagni,  February,  1889. 

2591.  Bull,  Chas.  S.,  Extraction  of  cataract  witliout  iridectomy.  The  New 

York  Med.  Record,  October  5,  1889. 

2592.  Berry,  De  Tenclavement  de  iris  consecutive  a  I'extraction  de  la  cat- 

aracte.    Paris,  1889. 

2593.  Little,  David.  Extraction  of  senile  cataract.     Brit.   Med.  Journal. 

February  23,  1889. 

2594.  Deeren.  Quelques  observations  sur  les  procedes  de  maturation  arti- 

ficiele  de  cataract.     Recueil  d'Opth.,  May. 

2595.  Doyne.  Peculiar  form  of  lens  degeneration.     Ibid.,  p.  113. 

2596.  Eales.  Foreign  bodies  in  the  lens.   British  Med.  Journal,  October  26. 

2597.  Martin,  Emil,  La  suture  de  la  cornee  dans  operation  de  la  cataracte. 

Recueil  d'Opth.,  May. 

2598.  Hosch,  Fr.,  Zur  casuistic  der  linsen  iiapsel  verletzung.     Arcli.  fur 

Augenheilkunde,  XX,  1,  2.  Zur  Erblichkeit  des  grauen  staars. 
Korresp.  Blatter  fur  Schweizer  Aerzte,  No.  19. 

2599.  Fuchs,  E..  Uber  traumatische  linsen  trubung.    Wiener  Klin.  Woch- 

enschrift, No.  3,  S.  53. 

2600.  Fage,   A.,   Contribution  a  I'etude  des   hemorrhagies  intraoculaires 

consecutives  a  la  extraction  de  la  cataracte.  Arch.  d'Opthal.,  July. 

2601.  Grolman,  W.   von,   I^ber  micropthalmus  und   cataracta   congenita 

vaculosa.     Graefe,  Vol.  XXXV,  B.  3  and  4. 

2602.  Guerison,  Ossification  totale  de  la  choroide;  glaucoma  sympathtique 

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2604.  Gunn,  M.,  On  the  actiou  of  the  aqueous  on  lenticular  substance. 

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2605.  Galezowski,  Extraction  de  la  cataracte  et  iridectomie.     Soc.  Opth. 

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2606.  Iliggius,   Charles,    On   extraction  of   immature   cataract.      Lancet, 

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2607.  Hirschberg,  J.,   Uber  staar  operation   und  diabetischer  alterstaar. 

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2608.  Noyes,  Henry  D.,  Considerations  concerning  extraction  of  hard  cat- 

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2609.  Hache.  Edmoud,  Sur  la  liy.iloide  et  la  zone  do  zinii.   Recueil  d'Opth. 

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2610.  Muttemaier,  Herman,  Uber  das  vorkommen  von  glaucom  in  cata- 

ractosen  augen.     Ing.  Dissert. 

2611.  Ferrer,  H.,  Report  of  a  series  of  106  cases  of  extraction  without  iri- 

dectomie. 

2612.  Jacobson,  J.,  Die  extraction  mit  der  kapsel.     Centralblatt  f.  Prakt. 

Augenheilkunde,  May. 

2613.  Chisholm,  Julian  J..  The  after  treatment  of  cataract  extractions. 

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2614.  Knapp,  H.,  Cataract  extraction  and  discussion.     New  Jork  Acad- 

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2615.  Keyser,   P.   D.,   Two  cases  of  removal   of  spontaneous   dislocated 

lenses  from  the  anterior  chamber  of  the  eye.     Centralblatt  fur 
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2616.  ,  Discission  of  cataract.    The  Times  and  Register,  May  25. 

2617.  Kazarow,  J.,  Zur  frage  der  suctions  methode  der  cataract  extrac- 

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2618.  DeWecker,   L.,   Lavenir  de  I'extraction  de  la  cataracte.     Annales 

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2619.  Lawreutiew,  Bericht  uber  das  dritte  hundert  der  cataract  extrac- 

tion.   Wjestnik  Opth.,  Vol.  Ill,  p.  269. 

2620.  Lippineott,  J.  A.,  Irrigation  of  the  anterior  chamber.    Amer.  Opth. 

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2621.  Magnus,  Hugo,  Anatomische  studien  uber  die  aufange  des  alter- 

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2622.  Martin,  E.,  La  suture  de  la  cornee  dans  operation  de  la  cataracte. 

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2623.  Pagenstecher.  IT.,  Uber  cataract  extraction  in  der  kapsel.     Seventh 

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2624.  Parisotti,   Sur  la   maturation  artificielle  de  la   cataracte.     Recueil 

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2625.  Romie.  De  la  panopthalmie  cliez  <(Mtaiiis  ()[i('il's  de  cataracte.    Ann. 

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2626.  Rutiiiiau.   Considerations  relative  a  la  structure  et  la  traitement 

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2627.  Schirmer.  Otto.  Histologische  uud  ebemische  nutersuchungen  uber 

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2628. .  Zur  patbologischen  anatomic  uud  pathogenese  des  schicbt- 

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2629.  Steffan.  IMiil.,  Weitere  erfahrungen  und  studien  uber  die  cataract 

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2630.  Suarez,  Ferdinand,  Sur  la  suture  de  la  eornee  dans  operation  de  la 

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2631.  Ayres,  S.  C.  Extraction  of  cataract  without  iridectomy  or  simple 

extraction.     American  Journal  of  Opth.    May. 

2632.  Schlosser.  Uber  die  lymphbahnon  der  linse.    Munchener  Med.Woch- 

enschrift.  Xo.  7.  1889. 

2633.  Saunders,   A.   R.,    Traumatic   dislocation   of   tlie   lens,    fluminating 

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2634.  Serebreniucowa.  E.,  Bericht  uber  zwei  hundert  von  cataract  extrac- 

tionen  in  Land  krankenhaus  zu  Perm.  Wjestnik  Opth.,  No.  1.  p.  41. 

2635.  Scimeny,  Sull  ast.vgmatismus  corneale  in  seguito  ad  estrazioni  di 

cateratta.     Annali  di  Ottalm.,  XVIII.  4,  5,  p.  299. 

2636.  Thomas.  Chas..  A  report  of  120  cases  dt  cataract  extraction.   Journ. 

of  Opthal.  Otologic  and  Laryngologie.  Vol.  I.   January. 

2637.  Treacher  Collins,  Hernia  of  the  lens  through  a  corneal  perforation. 

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2638.  Wagenman,   A..   Uber  die  von  operations  uarbeu  und  vernarbten 

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2639.  Collins,  W.  J.,  Paralysis  of  fifth  nerve,  associated  with  cataract. 

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2640.  Wickerkiewicz,  R..   Uber  das  geeignetste  verfahren  der  kapseler- 

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2641.  Wickerkiewicz,  Bolelas,  Cur  la  cystotomie  par  rapport,  a  I'extrac- 

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2049.  Critchett.  Anderson,  The  treatment  of  innnatiire  cataract.     British 

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2050.  Ilaase,  C.  II..  Beitrage  ziir  operation  des  .urauen  staars.     Festschr. 

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2653.  Fager,  A.,  Infection  tardive  de  I'oeil  apres  operation  de  la  cataracte. 

Annales  d'Oculistique.    May,  June. 

2654.  Angello.  Leda.  Delire  chez  les  operes  de  cataracte.     Recueil  d'Opth. 

July. 

2055.  Bourgeois.  A..  De  la  kystectomie  dans  operation  de  cataracte.     Re- 

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2056.  Berry.  Spontaneous  purulent  hyalitis  nine  months  after  a  success- 

ful cataract  extraction.     Oi)th.   Society  of  the  United  Kingdom. 
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2057.  Brailey.  Points  in  the  development  of  cataract.     Oplh.  Society  of 

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2059.  Blubaugh.  The  removal  of  a  dislocated  lens  Avith  the  a«iueous  bi- 

dent.     Times  and  Register.  August  30.  1890,  p.  199. 

2660.  Bull.  Simide  oi)eration  for  the  extraction  of  cataract.     Amer.  Opth. 

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2663.  Collins,  Treacher,  Abnormalities  of  the  zonula  of  Zinu.    Royal  Lon- 

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2664.  Cicardi.  Uni  casi  di  sublu.ssazione  della  lenti  cristallina.     Annal. 
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2665.  Cisseb,  E.,  Eine  seltene  angeboreue  auomalie  der  linse.     Zeheder's 

Klin.   Monatsbl.    August. 

2666.  Dobard,   Considerations  generales  sur  I'operation  de  la  cataracte 

Chez  les  enfants.     Recueil  d'Opth.    September. 

2667.  Dufour,  Des  cataractes  secondaires  au  point  de  vue  operatoire.   Soc. 

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2668.  DeWecker,  Un  quart  de  siecle  consacre  an  perfectionnement  de 
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2669.  Bock.  E.,  Fun  falle  von  cataracta  nach  menningitis  be!  jugendliche 

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2670.  Ferri,   Complicazioni  postume  dell  operazione  di  cataratta  e  loro 

cause.     Annal.  d'Opth.,  XVIII,  6.  p.  493. 

2671.  Fox-Webster.  The  absorption  of  immature  cataract  by  manipula- 

tion conjoined  with  installation.   Times  and  Register,  1890,  No.  25. 

2672.  Gefaner,   Beitrag  zur  kentniss  der  glasshautigen  auf  der  linsen- 

kapsel  und  die  descemetischen.    Memlian.    Graefe  Arch.,  XXXVI, 
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2673.  Norris.   Gordon.   George   Henermant  seine   deutsche   beschriebung 

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2674.  Gifford,  Ein  neuer  staar  extractions  verband.     Arch.  f.  Augenheil- 
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2675.  Grandelement,  Des  conditions  des  success  dans  I'operation  de  la 

cataracte.    Lyon  Med.  Journal.  No.  29.   1890 

2676.  Graefe,  R.,  Uber  450  extractions  von  cataracta  senilis  ohne  iridecto- 

mie.    Arch.  f.  Augenheilkunde,  XXII,  S.  355. 

2677.  Hess,  Carl,  Weitere  untersuchungen  uber  angeborene  misbildungen 

des  auges.    Graefe  Arch.,  XXXVI,  B.  1. 

2678.  Haskel-Derby.  Eight  cases  of  dolible  zonular  cataract  in  ten  mem- 

bers of  same  family.    Ann.  Opth.  Soc.   1890. 

2679.  Hirschberg,  J.,  Zur  geschichte  der  staar  ausziehung.     Hirschberg's 

Centralblatt,  p.  198. 

2680.  J.  Accacis  da  Gama,  Cataract  operation  without  iridectomy.    Brit. 

Med.  Journal,  November  16,  1889. 

2681.  Lippincott,  J.  A.,  On  intraocular  syringing  in  cataract  extraction, 

with  a  report  of  53  operations.    Qpthalmic  Review.    July. 

2682.  Kazarow.  J.  N.,  Zur  frage  der  cataract  operation  durch  aussaugen. 

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Arch.  f.  Augenheilkunde,   Heft.  2. 

2687.  Keyser,  Soft  cataract.    Times  and  Register.  XXI.  20,  p.  257. 

2688.  Iwan  M.  Burnett,  Regular  astygmatism  following  cataract  extrac- 

tion.    American  Journal  Opth.     1889. 

2689.  Lucanus.  Ein  fall  von  monocularem  doppelseheu.     Klin.  Mon.  Bl.  f. 

A..  XXVIII,  S.  282. 

2690.  Magnus.  Hugo,  Experimentelle  studien  der  ernahrung  der  krystal- 

linse  und  uber  cataractbildung.    Graefe  Arch.,  Vol.  XXXVI,  B.  4. 

2691.  McHardy.   Artificial   maturation   of   immature   senile   cataract  by 

trituration.    Opth.  Society  of  United  Kingdom.    Arch.  f.  Augenh.. 
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2692.  Straub,  M.,  Die  concavitate  des  vodern  zonula  blattes  nach  vorn. 

Arch.  f.  Augenheilkunde.  Heft.  2. 
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2694.  Mario w,  J.  W.,  Preliminary  capsulotomy  in  the  extraction  of  cata- 

ract.   New  York  Med.  Journal,  LH,  No.  13,  p.  357. 

2695.  Parinaud,    Du   delire   apres   I'operation   de  la   cataracte.      Societe 

Francaise  d'Opthal.    Arch.  f.  Prakt.  Augenheilkunde,  p.  334. 

2696.  Rolland.  Mayens  tres  practiques  et  asepsis  pour  la  cataract.     Re- 

cueil  d'Opth.,  March  and  February,  1890.  De  la  operation  de  la 
catracte  chez  la  maladies  ambulants  et  de  la  responsabilite  modi- 
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2697.  Kerschbaumer,  Rosa,  Bericht  uber  200  cataract  extractions.    Arch. 

f.  Augenheilkunde,  XXII,  Heft.  2. 

2698.  Kalisch,  Richard.  The  arrest  and  partial  resorption  of  immature 

cataract,  with  restoration  of  reading  power.  Medical  Record. 
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2699.  Schoen,  Bericht  zu  Prof.  Magnus  Aufsatz.    Graefe  Arch.,  XXXVI, 

B.  1. 

2700.  Schweiggger,  Uber  die  operation  unrifer  stare.     Berliner  Med.  Ge- 

sellschaft.     Hirschberg's  C.  Blat.,  206. 

2701.  Schnabel,  Uber  cataract  operationen.    Wiener  Med.  Presse.  No.  19. 

2702.  Schirmer,  R.,  Uber  indirecte  verletzung  der  voderen  linsenkapsel 

und  des  sphincter  iridis.     Zehender's  Klin.  Monatsch.    May.  1890. 

2703.  Scimeni.  Sull  modificaziono  della  curvatura  della  cornea  in  segulta 

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1890.     2704.  ShioMs,  Cha.s.,  Wlion  shall  we  oporate  cataract  and  strabismus  in 
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2705.  SAvanzy.   Series  of  100  cataract  extractions.     New   York   Medical 

Journal,   IJI.  p.  146.     Remarks  on  cataract  extraction.     British 
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2706.  Treacher  Collins,   Glauoma  after  cataract  extraction.     Opth.  Soc. 

of  the  United  Kingdom.     British  Med.  Journal,  February  8,  1890. 

2707.  Trousseau,   Les  maladies  generales  et  I'operation  de  la  cataracte. 

Recueil  d'Opth.     March. 

2708.  ^Tyner.  T.  J..  Preliminary  capsulotoniy  in  the  extraction  of  cataract. 

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2710.  Valk,    Francis,    Operation   of   cataract   without   iridectomy.      N.   Y. 

Med.  Journal,  LI,  16,  p.  431. 

2711.  Yalude,  Accidents  centraux  consecutive  a  I'operation  de  la  cataract. 

Soc.  Franc.  Opth.     1890. 

2712.  Wood.  Hiram,  Intraocular  lieniorrliage,  consecutive  to  cataract  ex- 

traction.    Med.  Record.  May  .31. 

2713.  Webster.   Traumatic  dislocation  of  the  lens.     N.   Y.   Med.  Record, 

LII,  p.  11  and  295. 
2714. ,  Fatal  meningitis  subsequent  to  panopthalmitis  after  extrac- 
tion.    Arch.  f.  Augenheilkunde.  XXI.  2.  S.  191. 

2715.  Ci-osz,   Emil,   Cataracta   partiales   trniiniati<-a.     (Szenieszet.   No.   1.) 

Arch.  f.   Frakt.  Aug..   p.  316. 

2716.  leweski,  F.  O.,  Cataract  and  xerosis  conjunctivae  bei  den  arbeitern 

der  Glasfabriken  Wjestnik  Opth.    ;May  and  June. 

2717.  (xuaita.   Panopthalmitis  six  monat  nach  staar  operation.     Italien- 

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2718.  ,  Experimenteli  reifung  des  staares. 

1891.    2719.  Berry.   Unusual   itsuIIs   of   cataract    extraction.      Opth.    Society   of 
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2720.  Czermak,  W..  Di-ei  fallc  von  iiili-acai»sii];;rer  aurs.-iugung  ih's  alter- 

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2721.  Chibret,  A  prospus  du  niccliaiiisiiie  de  rinlcctic.n  aiircs  I'operation 

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2722.  Bernh.'ird.  Dub..  Beit  rag  zur  keiitniss  der  cataract  zouularis.  (Jr.-iefe 

Arcli..   ^•(.l.   XXXVII.  B.  4. 

2723.  Dimiiier.    I'..   Yaiv  glasc  r  correction   lici   aplialvic      Zeliendt-r's    Klin. 

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2724.  Fischei-.  Kicii..  Sticli  verlctzung  cines  jinges.     Walirscheinlicli  unge- 

(Iciintc  /.cireissung  der   vodcicn   liiiscn]<aiiscl     volkoniiiicne   wied- 
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2727.  Thuin|)s<)n.  .T.  Tatliaui,  Nott-  on  Foorstcr's  artitirial  riiwning  of  cata- 

ract.    Koyal  London  Optb.  Hospital  Koporls,  Vol.  XIII.  Part  I. 

2728.  Melliugor.  Carl.  Exporinientolli  T'ntersnchnuf^en  uber  die  enstebung 

der  in  letzere  zeit  bekannt  swordene  trubuns  dor  hornbaut  nach 
staarextraction. 

2729.  Mules.  The  formation  and  patbobiiiv  of  pyraiiiidai  and  ct-ntral  an- 

terior capsular  cataracts.     Opth.  Society  of  tli<-  United  Kingdom. 
October  16,  1890.     Hirschberg's  Centralblatt,  p.  339.    1891. 

2730.  Xatanson.  Spontane  aufsaugnng  cataracte  linse.     Zehender's  Klin. 

Mouatsbl.  f.  A.,  XXIX,  Bd.,  S.  423,  December.  1891. 

2731.  Risley,   S.   D.,   Incipient  cataract:   aetiology,    treatment   and   prog- 

nosis.    Opthal.  Review,  August,  1891. 

2732.  Scliirmer,  Otto,  Zur  pathologiscber  anatomic  imd  i)atliogenese  des 

centralstaars.     S.  Arch..  XXXVII,  B.  4. 

2733.  Seabrook,  The  natural  course  of  cataract.     Med.  Record.  Septem- 

ber 12,  1891. 

2734.  Topolanski.  Dr.  A.,  Uber  den  bau  der  zonula  und  umgebung  nebst 

bemerkungen   uber   das    albinotische   auge.      Graefe   Arch.,    Vol. 
XXXVII,  B.  1. 

2735.  Treacher,   Collins,   On  the  development  and  abnormalities  of   the 

zonula  of  Zinn.    Royal  London  Opth.  Hospital  Reports,  Vol.  XIII, 
Part  I. 

2736.  Wagenman,   A.,   Zur  anatomie  des  dunnhatitigen   nachstaars,   etc. 

Graefe  Arch.,  XXXVIII,  B.  2. 

2737.  Webster,  Note  on  a  case  of  diabetic  cataract. 

2738.  Wray,  Chas.,  Points  on  the  treatment  of  lamellar  cataract.    Opthal. 

Review,  September,  1891. 

2739.  Alexejew.  Angeborener  staar  auf  beiden  augen.     Wroschdjonnaja 

katarakta  na  oboich  glasach.     Russkaja  Medizina,  No.  45,  p.  716. 

2740.  British  Medical  Association,  Section  of  Optbalmology.    July.    The 

treatment  of  infantile  cataract.     Opth.  Review,  p.  315. 

2741.  ,  Some  points  in  the  treatment  of  lamellar  cataract.     Ibid. 

2742.  Burnham,  A  few  remarks  on  the  treatment  of  lamellar  and  senile 

cataract.     New  York  Med.  Record.  August  22. 

2743.  D'Oench,  A  case  of  muscular  zonular  cataract.     Arch.  Optli..  XX, 

p.  258. 

2744.  Kessler,  Ein  bijzonders  vorm  van  angeborener  cataracta  zonularis. 

Graefe's  Arch.  f.  Opth.  voor  Geneesk.  II,  No.  21. 

2745.  Philipsen,  H.,  Einige  notizen  von  opthahnologisch  diagnostischem 

inhalt.     (1)  Die  diagnose  des  schichtstaars  durch   die  form   der 
pupille  bei  schrag  einfallendem  licht.    Hosp.  Tid.,  p.  783  u.  S.  868. 


542 

1891.     2740.  Schnabel,  Ueber  tarnracta  der  kinder.     Wiener  Med.  Wochenschr., 

No.  4. 
^'-iT. .  Bemerlcunjien  uber  die  liatarakte  der  kinder.     Mitteil.  der 

Ver.  d.  Aerzte  in  Denmark.  1890.    Craz.,  XXVII,  S.  65. 

2748.  Wray,  C,  Points  in  the  treatment  of  lamellar  cataract.    Opth.  Re- 

view, p.  263. 

2749.  Wilson.    Harold,    Hereditarer   kongenitaler   staar.      Journ.    d'Opth. 

Otol.  and  Laryng..  Oktober.  (Yon  31  nacbkommen  bis  zur  4. 
Generation  waren  16  mit  kongenitalem  staar  behaftet.) 

2750.  Collins,  Extensive  rupture  of  the  posterior  capsule  of  the  lens  fol- 

lowing a  blow  on  the  eye  from  a  stone.  Trans,  of  the  Opth.  Soc. 
of  the  United  Kingdom,  XI,  p.  126. 

2751.  Wood,  Rupture  of  the  capsule  of  both  lenses,  with  other  damage 

to  the  eye:  from  pleuro-pneumouia.  cough  (?).  Montreal  Med. 
Journal,  XX,  p.  87.    1891-92. 

2752.  Achun,  A.,  Ein  fall  von  luxation  der  linse  und  abreissung  der  regen- 

bogenhaut  mit  ciliarkorper  bei  integritat  der  ausseren  augen- 
haute.  (Slutschaj  wiwicha  chrustalika  i  otriwa,  radus  schnoj  obo- 
lotschki  s  ciliarnimtjelom  prizelosti  naruschnich  obolotschek 
glaza.)    Wjestnik  Opth.,  VIII,  3,  p.  222. 

2753.  Bettmann,  Boerne,  Dislocation  of  the  lens  into  the  anterior  cham- 

ber. American  Journ.  of  Opth.,  p.  159,  und  Chicago  Med.  Record, 
p.  317. 

2754.  Deschamps,   A.,   Deux  observations  de  luxation  traumatique  des 

cristallins.    Dauphine  Med.  Grenoble,  X*V,  p.  57. 

2755.  Mercanti,  Un  raro  caso  di  lusazione  incompletamente  sottocongiun- 

tivale  del  cristallino.    Annali  di  Ottalm.,  XX,  p.  365. 

2756.  Rossigneux,  Luxation  du  cristallin  et  decoUement  du  corps  ciliaire. 

Province  Med.,  21.    Fevrier  et  France  Med.,  No.  10,  p.  152. 

2757.  Sureau,   H.,    Contribution  a  I'etude   des   luxations   spontanees   du 

cristallin.    These,  de  Paris. 

2758.  Theobald.    Dislocated   lens.     (Amer.    Opth.    Soc.)    Amer.   Journ.   of 

Opth.,  p.  231,  und  Med.  Record,  October  3. 

2759.  Trousseau,  I/intervention  dans  les  luxations  du  crista lllin.    La  Pra- 

tique Medic,  de  Baratoux,  January  13. 
2700.  Wood,   White,    Subcon.iunctival   dislocations  of  the  lens.     Lancet. 
No.  3522.    February  28. 

2761.  American    Opthalmologicnl    Society,    Annual    Meeting    September. 

1891.    Dislocated  lens.     Amer.  Journ.  of  Opth.,  p.  231. 

2762.  Puschkin,  Ectopia  lentls  utriusque  oculi.     W.iestnik  Opth.,  VIII.  3. 

p.  224. 

2763.  Neve.  C.  F..  Remarks  on  diabetic  cataract.     Indian.  Med.  Record, 

p.  373. 

2764.  Willlot,  M.,  De  la  cataracte  luMiiorrhagiiiue.     These,  de  Paris. 


543 
2765.  American    Opthalmological    Society,    Annual    Meeting    September, 

1891.     Glaucoma  after  extraction  of  cataract.     Amer.  .Tourn.  of 

Optb.,  p.  231,  and  Opth.  Review,  p.  37G. 
276r..  Autonelli,  Studio  critico  ed  osservazioni  cliniclie  iutoruo  alia  natur- 

azlone  artificiale  della  cataratta.     Napoll. 

2767.  Archangelskaja,  A..  Bericht  uber  !(»()  staarcxtractiouon  iu  dcr  land. 

(Sems   two.)    Praxis.     (Ottsclijoz  o  sotne  extraktij   katarakt  w 
skemskci  praktika.)  Mediziniskoje  Obozrenje,  XXXI,  Nr.l5,  p.l98. 

2768.  Barr.  S.,  Die  extraktion  des  beginnenden  staares.     New  York  Med. 

Record,  December  12. 

2769.  Bono.  Ueber  staarextractlon.     Verli.  d.   X.   Intornat.   Med.   Kongr., 

1890.  IV,  10.  p.  154. 

2770.  Broekmann,  Drake,  Preliminary  capsulotoray  in  the  extraction  of 

cataract.     Amer.  Journ.  of  Opth..  p.  90. 

2771.  British  Medical  Association.   Section  of  Optlialniology.  .luly,  1891. 

Iridectomy  or  non  in  cataract  extraction.    Opth.  Review,  p.  315. 

2772.  BuUer.  F.,  Glaucoma  after  extraction  of  cataract.     Trans,  of  the 

Amer.  Opth.  Soc,  27th  Meeting,  p.  120,  and  Amer.  .lourn.  of  Opth.. 
VIII,  p.  313. 

2773.  Carrow,  F.,  A  review  of  a  year's  work  in  the  treatment  of  cataracT. 

Trans.  Michigan  Med.  Soci..  XV,  p.  214.    Detroit,  1891. 

2774.  Cliisholm.   J.   J.,    How   should   cataract  operation   be  performed? 

Journ.  Amer.  Med.  Assoc,  XVII,  p.  329.    Chicago,  1891. 

2775. ,  The  after  treatment  of  cataract  operations.     Verh.  d.  X.  In- 

ternat.  Med.  Kongr.,  lA',  p.  13.    1890. 

2776.  Critfhett,  A.,  Capsulotomy  knife.    Trans,  of  the  Opth.  Soc. 

2777.  Aguilar.  Blanche.  Cataracte  hereditaire.     (Compt.  rendu  de  la  sec- 

tion opthalmologique  du  Congres  Medic,  de  Valence.)    Revue  Gen- 
erate d'Opth.,  p.  352. 

2778.  Bleibaugh.  C.  B..  Report  of  six  recent  cases  of  cataract.     Trans. 

Med.  Soc.  of  West  Virginia,  p.  865.    Wheeling. 

2779.  Brailey,  On  some  points  in  the  development  of  cataract.    Trans,  of 

the  Opth.  Soc.  of  the  United  Kingdom,  XI,  p.  66. 

2780.  Dubief.   Note   sur  'quelques   recherches   bacteriolngiques   dans   les 

cataractes.    Annal.  d'Oculist,  T.  CVI,  p.  182. 

2781.  Green.  T.,   Notes  of  twenty-one  cases  of  cataract  occurring  in  a 

single  family.    Trans,  of  Amer.  Opth.  Soc,  Twenty-sixth  Meeting, 
p.  690.  (Bei  70  bekannten  nachkommen  einer  familie  21  staarfalle.) 

2782.  Hall,  G.  C,  Cases  of  hereditary  cataract.    Indian  Med.  Record,  p. 

194.    Calcutta. 

2783.  Knaggs.  L..  On  lenticonus.     I.auci't.  II,  p.  657. 

2784.  Magnus,    H.,   Die  grundclemente   der  staarbildung   in   der  senilen 

linse.     Arch.  f.  Augenheilkunde,  XXIV,  S.  1. 


544 

1891.     2785.  ,  Ueber  blasenbikluns  nni  linseuaqiialor.     Klin.  Monatsbl.  f. 

Augenheilk..  S.  291. 
278(i.  Natanson,  A.,  Spontane  resorption  des  alterstaares.     (Samordnoje 

wsariwanje  startsclieskoj.)     AVratsch.,  No.  45,  p.  996. 

2787.  ,  Spontane  intracapsulaire  recorptlou  oines  alterstaares.    Klin. 

Monatsbl.  f.  Aui,M'nbeilk.,  S.  423. 

2788.  Norris,  G.,  Die  katarakt  depressionen  in  SkandiTiavieu  in  der  letzteu 

Halfte  des  18.     Jahrhiinderts,  Nord.  Opth.  Tidslir.,  IV,  1. 

2789.  Panas,  Cataratte  mature  ed  iinpermature.    Boll.  d'Ocul.,  XIII,  p  23. 

2790.  Yennenian,  E.,  Un  cas  de  lenticone  double  anterieur.    Annal.  d'Ocu- 

list,  T.  CV,  p.  158. 

2791.  Weeks.  A  ease  of  lenticonus  posterior,  with  remarks.     Arch.  Opth.. 

XX,  p.  2(50. 

2792.  Collins,  W.  .!.,  On  some  exceptional  cases  of  operation  for  cataract. 

Lancet,  II,  p.  479. 

2793.  Cross,  F.  R.,  Iridectomy  or  no  in  cataract  extraction.     Brit.  Med. 

.Tourn.,  II,  p.  472. 

2794.  Dimissas,  Sur  la  simplification  de  I'exlraction  de  la  cataracte.     Re- 

cueil  d'Opth.,  p.  13G. 

2795.  Finck,  L.,  Method  of  operation  for  cataract  in  Bijnor  Dispensary. 

with  the  result  of  100  cases  during  1890.  Indian  Med.  Gaz.,  XXV, 
p.  358.    Calcutta,  1890. 

2796.  Fox,  L.  W.,  Improved  eye-pairs  for  the  after  dressing  in  cataract 

operation.     Med.  News,  Philadelphia,  p.  851. 

2797.  Frothingham,  C.  E.,  Remarks  on  the  need  of  more  efficient  protec- 

tion of  the  eye  after  cataract  extraction,  and  an  improved  appa- 
ratus for  the  purpose.  .Journ.  Amer.  Med.  Assoc,  Chicago,  p.  335. 
(Eine  Augenmaske  statt  des  Occlusiv-Verbandes.) 

2798.  Fulton,  J.  F.,  Treatment  of  immature  cataract.     Amer.  Journ.  of 

Opth.,  p.  165. 

2799.  Gaupillat,   Pansement  apres  I'operation   de  la  cataracte  a  grand 

lambeau  superieur.    Revue  Generale  d'Opth.,  p.  339. 

2800.  Gayet,  Essai  sur  la  recherche  de  I'acuite  visuelle  apres  I'operation 

de  la  cataracte.  Necessite  d'employer  partout  une  methode  uni- 
forme.    V.  Melmholtz'sche.  Festschr.,  S.  62. 

2801.  Guaita,  Cenno  preventivo  di  uno  studio  sperimentale  e  clinico  nella 

maturazione  artificiale  della  cataratta.  Annali  di  Otlalm.,  XIX, 
5,  0,  p.  517. 

2802. ,  Pahoftalmite  tardiva  siluppatata  sei  mesi  dopo  un  ablazione 

di  cataratta.     Ibid.,  p.  515. 

2803.  Gracfc,     A.,     Zur     wundbehandlung     der     katarakt     extraetionen. 

Deutsche  Med.  Wochenschr.,  No.  43. 

2804.  Graves,  A.  C;  Cataract  extraction.    West.  Med.  and  Surg.  Reporter. 

SI.  .Toseph,  1891-92,  I,  27. 


545 
is«n.      2S05.   (Jivof.    U..    Ueport    ..f    ir.n    siiiii.lc    .'Xiriictioiis    nf    sciiil,-    i:il:ir;ict. 
Tniiisliiti'd  l.y  Dr.  A.  .1.  Spnliliiiir.     Ar.li.  OpUi..  XX.  p.  30;j. 
280(1.   DfUlschiimiiifs  I'.citrimc  /ur  A\i.i;ciilicilk..   III.  S.  .VJ. 
2807.    llaiiscii.  ('.  .M..  K.Miakliuii  ilcr  liusekaiiscl.     Ilosp.  Tid.,  S.  (>S5. 


2808.    Il.u-lMii.   11..  Sucfcssful  ciiliiraci   rxtractioii 


ISC  of  adavanced 


retinitis  i,i.';im>nt..sa.      Mar.vlaii.l   Mr.l.  .louri...   XXIV.  p.  2C,r,.    Bal- 
timore.  lS'.tl-!»1. 

2800. .  Eiu  fall  vou  iris  prolaps  am  3.    Tagc  nacli  ciiu'r  katarakt  ex- 

traktion  oliue  iridoktomie.     Trolaps  rcponiorl;  Hoihing.     Arch.  f. 
Augenheilk.,  XXIV.  S.  50. 

2810. ,  Case  of  hernia  of  iris  occurring  ou  tiiinl  day  after  cataract 

extraction  without   iridectomy;  liernia   replaced:  recovery.     Arch. 
Opth.,  XX.  p.  81. 

2811.  Hjort.  rel.er  katarakt  extraktioii  ..line  iridcktmnic     Xm-sk.  .Magaz.. 

p.  (543. 

2812.  Holmes.  Spiccr.   llennirrliagc  following  extraclion  of  a   black  cata- 

ract in  a  highly  myopic  eye.  probably  associated  with  choroidal 

changes;    enucleation.     .lourn.   Amer.    Med.  Assoc.    XYI.    p.  83. 

Chicago. 
2Si;!.  Jacqiiin,   Pressure   on   the   globe   after   cataract    extraction.      Ibid. 

XVI.  p.  331. 
2814.  .  The  simple  extraction  of  cataract.     ^Maryland  Med    .lourn.. 

X.\I,  p.  67.    Baltimore.  1801-92. 
281.5.  .Tohannson.   E..    Katarakt   operatiouen   in   ausserklinischer   beliaud- 

lung.      (Livlandischer   Aerztetag.)      Walk.    September.    1801.     (St. 

Petersburger  ^led.  Wochenschr.i 
281().  Kerschbaumer,  Rosa,  Report  of  two  hundred  cataract  extractions. 

•Translated  by  Dr.  C.  A.  Wood.     Arch.  Opth..  XX,  p.  3-19. 

2817.  Knapp,  H..  Ein  fall  von  glaskorperblutung  nach  einer  staar  extrac- 

traktion.    Arch.  f.  Augenheilk.,  XXIII,  S.  272. 

2818.  .  The  occurrence,  prevention  and  management  of  prolapse  of 

the  iris  in  simple  extraction  of  cataract.     Trans,  of  the  Amer. 
Opth.  Soc.  27th  Meeting,  p.  80. 

2819. ,  Die  behandlung  der  kapsel  wahreud  und  nach  der  staar  ex 

traktion.    Verh.  des  X.  Interuat.  Med.  Congresses,  Bd.  IV.  4.  S.  1. 

28'20.  Kollock.  C.  X.,  Report  of  cataract  cases.  Trans.  South  Carolina 
Med.  Assoc,  p.  107.     Charleston. 

2821.  Eacqueur.  Teber  den  gegenwartigen  stand  der  lelnv  von  der  staar 

operation.     Deutsche  .Med.  Wochenschr..  Xo.  n.     (Xaturwissensch. 
Med.  A'erein  in  Strassburg.     Sitzung  vom  20.    Xovember.  1890.) 

2822.  Landolt.  Presentation;  de  quelques  instruments  ayant  trait  a  I'oper- 

ation  de  cataracte.     (Societe  Francaise  d'Opthalmologie.i    Arch. 
d-Opth..  XI.  p.  4G3,  545,  et  XII.  p.  323.  et  Annal.  d'Oculist.  T.  C\. 


546 

1891.     2823.  Lerebzenicowa.  E.,  Bericht  uber  300  katarakt  operationen.     Wjest- 
nik  Opth.,  VIII,  1,  p.  32. 

2824.  Lippincott,  J.  A.,  Routine  syringing  out  of  cortical  matter  in  cata- 

ract extraction,  as  illustrated  by  100  cases.  Trans,  of  the  Amer. 
Opth.  Soc,  27th  Meeting,  p.  85. 

2825.  Logetschnikow,   S.,   Eiue  staar  extraktion  bei   morbus  basedowii. 

Klin.  Monatsbl.  f.  Augenheilk.,  S.  277. 

2826.  ,    Staarextraction   bei  einer   krauken  mit  morbus   basedowii. 

(Slutschij  i  swletschenja  katakakti,  osloschnjonnoj  bolesnju  base- 
dowa.)    Westnik  Opth.,  Ill,  p.  219. 

2827.  Martin,   G.,   Une  complication  post-operatoire   de  la   cataracte   de 

Morgagni.    Societe  d'Opth.  de  Paris,  November  3. 

2828.  Mellinger,  C,  Experimentelle  untersuehungen  uber  die  entstehung 

der  in  letzter  zeit  bekannt  gewordenen  trubungen  der  hornhaut 
nach  staar  extraktion.  V.  Graefe's  Arch.  f.  Opth.,  XXXVII.  4, 
S.  159. 

2829.  Millee,   E.,   Extraction  du  cristallin  a  la  curette.     Nouvelle  anse 

fenetree.  Annal.  d'Oculist,  T.  CVI,  p.  2.  (Durch  einen  in  der 
Mitte  verlaufenden  Langsleisten  gefenstert.) 

2830.  Minor,  J.  L.,  A  report  of  twenty-five  cataract  extractions.     Arch. 

Opth.,  XX,  p.  69 

2831.  Murrell,   T.   E.,  To  what  extent  are  personal  restraints  essential 

during  healing  of  corneal  wounds?  Journ.  Amer.  Med.  Assoc, 
XVII,  p.  333. 

2832.  Neuschuler,    De   I'astigmatisme   post-operatoire.      Recueil    d'Opth., 

p.  515. 

2833.  Nikoljukin,  J.,  Bericht  uber  97  staar  operationen  in  der  Land  (Sems- 

two)  Praxis.  (Ottschjot  o  97  operatijach  katarakti  w  semskoj 
praktike.)    Wjestnik  Opth.,  VIII,  3,  p.  226. 

2834.  Nuel,  Sur  la  prophylaxie  de  la  suppuration  apres  I'operation  de  la 

cataracte.  (Societe  Fraucaise  d'Opthalmologie.)  Arch.  d'Opth., 
XI,  p.  463,  545,  et  Annal.  d'Oculist,  T.  CV,  p.  227. 

2835.  Norrie,  G.,  Die  katarakt  operation  in  Skandinavian  in  der  letzten 

Halfte  des  Jahrhunderts.     Nord.  Opth.  Tidsskr.,  IV,  p.  1. 

2836.  Ostwalt,  F.,  Einige  Worte  uber  glaserkorrektion  bei  aphakie.   Klin. 

Monatsbl.  f.  Augenheilk.,  S.  283. 

2837.  Parinaud,  H..  Le  prolapsus  de  I'iris  dans  I'extraction  simple  de  la 

cataracte.    Recueil  d'Opth.,  p.  321. 
2838. ,   L'enclavement  de  I'iris  dans  I'extraction  de  la  cataracte. 

(Societe  Francaise  d'Opthalmologie.)    Arch,  d'  Opth.,  XI,  p.  463, 

545,  et  XII,  p.  323,  et  Annal.  d'Oculist,  T.  CV,  p.  227. 
2839.  ,  II  prolasso  dell  iride  nella  estrazione  della  catei-atta.     Boll. 

d'Ocul.,  XIII,  10. 


547 
1891.     2840.   I'itts.    B..    CiitanKl    cxtrjK  lion.      'I'niiis.    .M("(li<;il    Assoc,    X.XXIII, 
p.  64. 

2841.  Pooley.  T.  li.,  Operation  lor  srcoiulary  cataracl.  followed  by  irido- 

cyclitis and  consecutive  glaucoma.   Anicr.  Journal  of  Dptli..  p.  'Ml. 

2842.  Kider.  W..  Report  of  a  case  of  fatal  in«'ninj,'itis  following  suppura- 

tion of  tile  i-ornea  after  cataract  operation.  'I'rans.  Med.  Society 
New  York,  p  .402.     I'biladulpliia. 

2843.  Roosa,  The  results  of  various  methods  of  extraction  of  cataract, 

illustrated  by  206  cases.    Arch,  of  Opth.,  XX,  No.  2,  p.  207. 

2844.  Santos,  Fernandez,  Extraction  du  cristallin  dans  myopie.     Compte 

rendu  de  la  section  opthalmologiiiue  du  Congress  Medic,  de  Val- 
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2845. .  I'n  accident  possible,  mais  remediable  dans  la  keratotomie. 

Revue  Generale  d'Opth.,  X.  3. 

284G.  Schnabel,  Entwickelung  der  staaroperationeu.  Allg.  Wien.  Med. 
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2847.  Serebrennikowa.  E..  Bericht  uber  30  staaroperationeu.     (Ottschjot 

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2848.  Smith.  E.,  Staar.    Wie  sollen  wir  uns  zur  kapsel  verhalten?    Neue 

Cystotompincette.    Journ.  Amer.  Med.  Assoc,  November  5. 

2849.  Suarez  de  Mendoza,  La  suture  de  la  cornee  dans  I'extraction  de  la 

cataracte.     Recueil  d'Opth.,  p.  577. 
2850. .  Nouveaux  faits  a  I'appui  des  avantages  de  la  suture  de  la 

cornee.  dans    I'operation    de    la    cataracte.     (Societe    Francaise 

d'Opthalmologie.)    Arch.  d'Opth.,  XI,  p.  463,  545,  et  XII.  p.  32.3, 

et  Annal.  d'Oculist,  T.  CV,  p.  265. 
2851.  Thomas.  A  report  of  50  cases  of  cataract  extraction.     .Tourn.  Opth. 

Otol.  and  Laryngol.,  p.  8. 
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Therap.  Med.  Chir.,  VI,  p.  269.    Paris,  1890. 
2S53.  VanDuyse.  De  I'hemorrhagie  choroidienne  grave  dans  Textraction 

du  cristallin  cataracte.     Annal.  d'Oculist,  T.  CV,  p.  112. 

2854.  Vignes,  Algunas  palabras  sobre  las  cataractas  secundarias.     Rev. 

Esp.  de  Oftal..  Dermat.,  Sif.,  etc.,  XV,  p.  289.     Madrid,  1891. 

2855.  ,  Quelques  mots  sur  les  cataractes  secondaires.    Recueil  d'Opth.. 

p.  65. 

2856.  Wageninann.  A..  Zur  anatomic  des  dunnhautigen  nachstaars,  nebst 

benierkuiigen  uber  die  heilung  von  Wunden  der  Descemet'scheu 

Membran.     V.  Graefe's  Arch.  f.  Opth.,  XXXVII,  2,  S.  21. 
28.57.  Wahlfors.  K.  R..  Bericht  uber  150  staarextraktionen.     Finska  La- 

karesallsk.  llandl..  XXXIII,  p.  333. 
2858.  Webster,  D.,  Notes  of  a  case  of  diabetic  cataract  operated  upon 

by  Dr.  C.  R.  Agnew.     Amer.  .Journ.  of  Opth.,  p.  131. 
2859. ,  Report  of  136  cases  of  cataract  extraction.     Trans,  of  the 

Amer.  Opth.  Soc,  27tli   Meeting,  p.  75. 


548 

1891.  2860. ,  Improved  eye-pads  for  the  after  dressing  in  cataract  oper- 

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2801.  DeWecker.   Ablation  de  la  capsule  anterieure.     Paris,   Lecrosnier 
et  Babe. 

2862.  — — .  Nouvean  procede  operatoire  de  cataracte  secondaire.     (So- 

ciete  Francaise  d'Opthalmologie.)    Arch.  d'Opth..  XI.  p.  463,  545. 
et  XII,  323,  et  Annal.  d'Oculist,  T.  CV,  p.  227. 

2863.  Wlckerkiewicz,  Ein  nngewohnliches  ereiguis  bei  einer  normal  aus- 

gefuhrten  alterstaar  extraktion.     (Polnisch.)    S.  A.  aus  Przeglada 
Lekarsk.   Nr.  38. 

2864.  Wolkow,    M.,    Zur   frage   der    staarextraktion     ohne     Iridektomie. 

(Kwoprosu    ob    extraktii    katarakti    bes    Iridektomii.)     Wjestnik 
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2864a.  Knaggs,  On  lenticomus.     Lancet.  1891. 

1892.  2865.  Abadie,  Nouvelle  methode  de  traitement  des  luxations  completes 

du  cristallin.     Soc.  d'Opth.  de  Paris.  July  5. 

2866.  Alt,  A..  A  case  of  acquired  anterior  polar  cataract.     Amer.  Journ. 

of  Opth.,  IX,  11,  p.  357. 

2867.  Arnold.  Th.,  Mittheilungen  uber  4000  staaroperationen,  ausgefuhrt 

von  Prof.  O.  Haab.     Arch.  f.  Augehheilk..  XXV,  1-2,  S.  41. 

2868.  Audibert,  Procede  nouveau  pour  I'aspiration,  en  un  seul  temps,  des 

eataractes  liquides  et  demi-molles;  description  d'une  aiguille  kera- 
totome  ci-euse  speciale.     Ann.  d'Ocul..  CVIII,  2.  p.  100. 

2869.  Aiisin,  Johann,  Das  eisen  in  der  linse.     Dorpat,  1891. 

2870.  Baker,  A.  R.,  The  pathology  and  treatment  of  infantile  cataract. 

Amer.  Med.  Assoc,  Detroit,  June.  7-10. 

2871.  Baker.  A.,  Infantile  cataract.    Amer.  Journ.  of  Opth..  IX,  11.  p.  350. 

2872.  Barsanti.    Cataracte    traumatique    developpe    soudainement    a    la 

suite  d'une  commotion  du  cristallin.     Rec.  d'Opth.,  No.  1,  p.  1. 

2873.  Beaumont.  W.  M.,  Aphakial  erythropsia.     Opth.  Rev.  No.  125,  p.  72. 

2874.  Bettman,  B.,  A  new  operation  for  the  speedy  ripening  of  imma- 

ture cataract.     Chicago  Medical  Recorder,  April. 

2875.  Bribosia,  Guerison  d'lm  aveugle  de  naissance;  operation  de  cata- 

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XII,  2,  p.  88. 

2876.  Cant,  W.  J.,  On  the  management  of  prolapse  of  the  iris  after  sim- 

ple cataract  extraction.     Brit.  Med.  Journ.,  No.  1659,  p.  834. 

2877.  Chisholni,  J.,  The  dislocation  of  :in  opaciue  lens.     Amer.  Journ.  of 

Opth.,  IX,  4,  p.  101. 

2878.  Colline,    E.    T.,    On    the    minute    anatomy    of    pynmiidal    cataract. 

Trans.  Opth.  Soc,  XII,  p.  89. 

2879.  Colline,  E.  T.,  and  Richardson  Cross,  Two  cases  of  epithelial  im- 

plnnt.-ition  cysts  in  the  anterior  chamber  after  extraction  of  cata- 
ract.    Trans.  Ojith.  Soc.  Nil.  ii.  17.". 


549 
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jNIon.  BL,  XXX,  S.  7:5. 
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In.  Diss.    Kiel. 

2883.  Dolschenkow,    W.,    P.ei-iciii    idicr   cinlinndcri    raiaiad    oiicnitionen. 

Wjestnik   Optli.,   IX.    1.   S.   -jr,. 

2884.  Dor,  Sur  le  traitement  de  la  ealaiaete  congenitale.     Conyr.   Franc. 

d'Opth.,  May  2.     Rapport  sur  le  traitement  de  la  cataiacte  con- 
genitale.    Compte  Rend,  de  la  Soc.  Franc.  d'Optli..  .May  2. 

2885.  Eiseck.   Eln   fall   von   Icnticonus   postiTidi-.      Klin.    Mon.    I'd..   XXX, 

S.  110. 
2880.   Erwin.   Treatment   of  incipient  eataraet.     .Vnicr.    .Med.   Assoc.,   De- 
troit, June  7-10. 

2887.  Friebis,  G.,  A  ease  of  congenital  ectopia  leutis.     Ebenda. 

2888.  Galezowski,   Sur  un  nouveau  procede  operatolre  d'extraction  des 

cataractes  incompletes.     Congr.  Franc.  d'Opth.,  May  2. 

2889.  ,  Nouveau  procede  operatoire  d'extraction  de  cataractes  in- 
completes par  incision  semielliptique  de  la  cornee  avec  sphinc- 
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2S90.  Gardner.  C.  R.,  Absorption  of  opacities  in  a  case  of  senile  cataract. 
Opth.  Rec.  I,  12,  p.  111. 

2891.  (Jayet.  En  eas  de  luxation  double  du  eristallin.     La  Province  Med.. 

No.  31. 

2892.  Hansen,  H.  .1..  The  extraction  of  double  congenital  cataract:  sym- 

pathetic  inliammatiou   after   second    ojjeration;    recovery.      Ann. 
of  Opth.  and  Otol.,  I.  2,  p.  137. 

2893.  Higgens,   Ch.,   Spontaneous   cure  of  cataract.     Oi)th.   Soc.   of  the 

United  Kingdom.     Case  of  spontaneous  disappearance  of  cata- 
ract.    Trans.  Soc,  XII,  p.  107. 

2894.  Hilbert  R.,    Zur   geschichte   der   kyanopie.      Arch.    f.    .Vugenheilk. 

XXIV,  3,  S.  240. 

2895.  Hirsehberg,    Ueber    kernstaar— Ausziehung.     Berlin.    Klin.    Woch.. 

No.   20. 

2890.  Knapp,    The   methods   and   results   of   simple   cataract   extraction. 

Amer.  Med.  Assoc,  Detroit,  June  7-10. 
2S97.  Kortnew,  A.,  Ueber  die  rachitiscbe  cataract.     Wjestnik  Opth..  IX. 
2,    S.    114. 

2898.  Landolt.  L'operation  de  la  cataracte  de  nos  Jours.     .\rch.  d'Opth.. 

XII,  9,  p.  529. 

2899.  Lapersonne.  De  Topportuuite  dc  liiitervention  dans  les  cataractes 

traumatiques.     Congr.  Franc.  d'Opth.,  May  2. 
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550 

1892.     2901.  Majinus.    H..    Dio   entwiekeluns  ties   alterstaares.      Augenarztliche 

unteiTichtstafelii     fur    deu    academischen    und    selbstimtericht. 

Heft.  II.     Breslau. 
2iM)2.  Milliken.  lujufy  of  the  lens,  with  cases.     Amer.  Med.  Assoc.  De- 
troit. June  7-10. 
200.",.  Mitvalsljy,  J.,    Ein   neuer  fall  von  lenticonus  posterior  niit   theil- 

Aveiser    persistenz    der    arteria    hyaloidea.      Centralbl.  f.    Prakt. 

Augenheilk.,  S.  05. 
2;)04.  .  Zur  kentniss  der  spontanheilung  des  senilen  totalstaars  ver- 

mittelst  der  intraeapsularen  resorption  nebs. 
2<Kt5.  .    Bemerkungen   uber   cataracta    Morgagniana.      Centralbl.    f. 

Prakt.  Augenheilk.,   S.  289. 
20(tO.  Nicati,  A  la  recherche  d'un  precede  d'extraction  de  la  cataracte 

cai)able  d'eviter  les  enclavements  et  les  hernies,  ou  d'en  attenuer 

les  eflfets.     Arch.  d'Opth.,  XI,  12,  p.  731. 
2907.  Nuel.  Troubles  corneens  consecutifs  a  I'extraction  de  la  cataracte. 

Bull,  de  la  Soc.  Franc.  d'Opth.,  p.  37. 
2008.  .   De  certain  troubles  corneens  consecutifs  a  I'extraction   de 

la  cataracte.     Bull,  de  la  Soc.  Franc.  d'Opth.,  p.  37. 

2909.  Pfluger,    Bemerkungen    zum    gegenwartigen    stand    der    frage   der 

staaroperation.     Ebenda.    S.  155. 

2910.  Pomeroy,  O.  D.,  A  report  of  fifty  cases  of  extraction  of  cataract 

without  iridectomy.     New  York  Med.  Journ.,  LVI,  20,  p.  535. 

2911.  Pooley,  Th.,  Operation  for  secondary  cataract,  followed  by  iridio- 

cyclitis  and  consecutive  glaucoma.     Amer.  Journ.  of  Opth.,  VIII, 
12,  p.  377. 

2912.  Randolph,  R.  L.,  A  series  of  fifty  consecutive  operations  for  cata- 

ract.    John  Hopkins  Hosp.  Bull.,  Ill,  20.  p.  19. 

2913.  Raschewski,  Einfluss  des  chinins  auf  die  eiterung  der  wunde  bei 

cataract  extractionen.     Wjestnik.  Opth.,  IX,  3,  S.  216. 

2914.  Richardson,  Cross  and  Treacher  Collins,   Implanation  cyst  in  the 

anterior  chamber  after  cataract  extraction.     Opth.   Soc.   of  the 
United  Kingdom,  July  8. 

2915.  Schanz,  J..  Ueber  den  einfluss  der  pupillaroflung  anf  das  sehen 

aphakischer.      Verhandl.    d.    Ges.    Deutscher   Naturforscher   und 
Aerzte.     Halle. 
2910.  Schulek,    W.,    Uebei-   eiue   neue   methode   der   cataract  extraction. 
Szemeszet,  No.   2. 

2917.  Snellen.    Hansen    (irut,    Critchett.    Secondi.    Sur   I'operation    de   la 

cataracte.     Ann.  d'Ocul.,  CVII,  p.  74. 

2918.  Spicer,  W.  T.  11..  Lamellar  cataract.    Trans.  Opth.  Soc,  XII,  p.  74. 

2919.  Ryerson.    Sterling,    Miscellaneous    facts    regarding    extraction    of 

cataract.     Opth.  Rec,  I.  7-8.  p.  258. 

2920.  Suarez  de  Mendoza.  Nouveaux  faits  de  suture  de  la  cornee  dans 

I'extiaclion  de  l;i  cataracte.     (3ong.  Franc  d'Opth..   May  2. 


551 
18J»2.     2021.  Terson.   Des  corps  I'stniiif^cis  dii  cristalliii;  indications  de  I'inter- 
vention  operatoire.     Arch.  d'Optli.,  XII,  3,  p.  15(5. 

2922.  Topolanski,  A.,  Linsenranderliebungen.  Klin.  Alon.  Bl..  XXX,  S.  89. 

2923.  Treacher    Collins,    The    niinnte    anatomy    of    pyramidal    cataract. 

Brit.  Med.  Joiun.,  No.  1692.  p.  006. 

2924.  Troussenu.   Quelques  accidents  des  operations  secoudaires.     Ann. 

d'Ociil..  CVII.  p.  .'^38. 

2925.  Wagner.  Bericlit  uber  ein  tausend  cataract  extract ioiieii   nach  A. 

V.  Gr.aele's  tmetliode.     Wjestnik  Opth..  IX,  1,  S.  1. 

2926.  Webster.   F.,  I'reliniinary  and  after  treatment  in  cataract  opera- 

tions. Annal.  of  Opth.  and  Otol..  April.  The  preliminary  and 
after  treatment  in  cataract  oijcrations.  Annal.  of  opth.  and  Otol., 
I,  2,  p.  88. 

2927.  Weeker,  L.  de,  Quel  progres  reste  a  realiser  pour  I'extraction  de  la 

cataracte?  Arch.  d'Opth..  XII,  6,  p.  250.  Extraction  simple  et 
extraction  combinee.     Arch.  d'Opth.,  XII,  11,  p.  657. 

2928.  White,  J.,  Immature  cataract  and  the  best  way  of  hastening  ma- 

turity.    Amer.  Med.  Soc,  Detroit.  June  7-10. 
2829.  Wickerkiewicz.    Ziu-    entstehung    bleibender    hornhaut    trubungen 
nach  cataract  extractiouen.     Deutsche  Med.  Wochenschr.,  No.  7. 

2930.  AVidmark.  .T.,  Om  staarsmittels  utveckling  itter  A.  v.  Graefe's  Dod. 

Hygiea.     September. 

2931.  Wray,  Charles.  Etiology,  prognosis  and  treatment  of  disseminated 

cataract.  Opth.  Soc.  of  the  United  Kingdom.  .January  28.  Aeti- 
ology, prognosis  and  treatment  of  disseminated  cataract.  Trans. 
Opth.  Soc,  XII,  p.  109. 

2932.  Zirm,   E..   Doppelseitiger  kernstaar.     Klin.    Mon.   Bl..   XXX,   S.   5. 

Beiderseitige  ectopia  lent  is  bei  zwei  geschwistern.     Wiener  Klin. 
Wochenschr.,  No.  21. 
1893.    2933.  Abadie.   Nouvelle  methode  de  traitemeut  des  luxations  completes 
du  cristallin.     Progres  Med.,  XVI,  p.  259. 

2934.  Albrand.  W.,  Bericht  uber  549  staar  operationen  der  Prof.  Scholer's 
Chen  Augenklinik  in  Berlin.  Arch.  f.  Augenheilkunde,  XXVI. 
Heft.  3  and  4. 

293.").  Audibert.  Considerations  pratiques  sur  deux  operations  de  cata- 
racte choroideenne  avec  issue  considerable  d'humeur  vitree 
suivies  de  succes  definitif.  Gaz.  Med.  Chir.  de  Toulouse.  XXV. 
p.  18. 

2936.  Baas,  K.  L..  Ein  fall  von  coloboma  lentis  congenitum  durch  per- 

sistierendes  fotalgewebe.     Klin.  Monatsbl.  f.  Augenheilk..  S.  297. 

2937.  Bauerlein.  A..  Meine  erfahrungen  uber  staar  und  staar  operationen 

in  25  jahren.     Wiesbaden.     .T.  F.  Bergmann. 

2938.  Bajardi.    P.,    Sul   grado   d'A.    corneale   negli    operati    di    cataratta 

specialemente  in  rapporto  col  metodo  operativo  e  con  le  compli- 
cazioni  avvenute  durante  e  dopo  I'estrazione.  (Rend.  del.  XIII. 
Congresso  della  Assoc.  Ottalni.  Ttal.)  .Vnnali  di  Ottaini.,  XXII 
p.  552. 


552 

1893.     2939.  Bates,  Notes  on  cataract  extraction.     Virginia  Med.  Month.,  Rich- 
mond, XX,  p.  217. 

2940.  Beaumont,  W.  M.,  The  progress  and  prognosis  of  incipient  senile 

cataract.    Provincial  Med.  .Tourn.,  February  1. 

2941.  Beccaria,  J.,  Sul  glaucoma  secondario  consecutivo  a  lussazione  del 

cristlalino.     Annali  di  Ottalm.,  XXII,  p.  115. 

2942.  Bettmann,  Ripening  of  immature  cataracts  by  direct  trituration. 

Ann.  Opth.  and  Otol.,  p.  2G.     St.  Louis. 

2943.  Black,  G.  M.,  A  successful  cataract  operation  performed  without 

the  observance  of  the  usual  rules.     Denver  Med.  Times,  1892, 
p.  380. 

2944.  Blancoeur,  Cataracte  consecutive  a  une  contusion  violente  du  globe 

de  I'oeil.     Annal.  de  la  Policlinique  de  Bordeaux,  No.  15. 

2945.  Blood,  On  a  series  of  282  extractions.    Liverpool  Med.  Chir.  .Tourn. 

July. 

2946.  Bourgeois,   Intervention  dans  les  luxations  pathologiques  du  cris- 

tallin.     Union  Med.  du  Nord-ant.     Reims,  XVII,  p.  172. 

2947.  Brainer,  J.  N.,  A  cataract  operation  in  a  much  mutilated  eye.  Trans. 

Michigan  Med.  Soc,  XVII,  p.  202.     Detroit. 

2948.  Cereseto,  Un  operations  di  eataratta  pres  estrazione  complicata  a 

rilevantissima  perdita  di  vitreo,  che  termina  tuttavia  sulla  guari- 
gione  lasciando  I'occhio  con  V2-3.    Gaz.  d'osp.  Milano.  XIV,  p.  450. 

2949.  Chauvel,  Etudes  opthalmologiques.     Affections  du  cristallin.     Re- 

cueil  d'Opth.,  March  et  April. 

2950.  Chisholm,  Anteror  dislocation  of  the  lens  in  a  child  with  ectopic 

pupils,  and  how  it  was  reduced.     Maryland  :Med.  .louvn..  XXIX. 
p.  353.     Baltimore. 
29.51.  Claiborne,  J.   H.,  Blunt  hook  and  book  knife  for  facilitating  the 
operation  for  secondary  cataract.  Med.  Record,  New  York,  p.  575. 

2952.  Dahlerup,  S.,  Die  behandlung  des  grauen  staars  (dan).     Hospital- 

stidende,  p.  885  u.  905. 

2953.  Dannich,  Paul,  Beitrag  zur  lehre  von  den  staar  operationen.  Inaug. 

Diss.  Halle  a.  S. 

2954.  Darier,   A.,   Behandlung  und  prophylaxe  der  infektosen  processe 

nach   staar  operation.     Bericht   uber  die   opth.   Gesellschaft  zu 
Heidelberg,  S.  99. 

2955.  Dennotkin,  S.,  Ueber  verminderung  des  traumatismus  bei  der  staar 

extraktion    (Ob    ummenschennii    traumatisma    dri    iswletschenii 
katarakti).   Chirurgitschesnaja  Letopis,  III,  No.  5,  p.  750. 

2956.  DeSchweinitz,  G.  E.,  Nuclear  cataract:  artificial  ripening  by  direct 
~  trituration;  extraction,  followed  by  prolonged  and  at  times  vio- 
lent dementia;  recovery  of  reason  and  good  vision.     Annal.  Opth. 
and  Otol.,  II,  p.  145.    St.  Louis. 

2957.  Dujardin,  L'extraction  de  la  cataracte  selon  la  derniere  mothode 

de  Daviel.    Journ.  des  Sciences  Med.  de  Lille,  p.  1. 


553 
IH..  2958.  l>unn.  ...  Thre.  .as.s  ...  .lislo.a.iou  of  the  h-ns  o..cumo.  in  cata- 
ract extraction;  showing  three  of  the  positions  the  lens  may  as- 
sume: question  as  to  the  regeneration  of  the  vitreous.  Ann. 
Opth.  and  Otol.,  II.  p.  250.     St.  Louis. 

09^9 ,  The  cataract  knife.     New  York  Med.  Record,  p.  GOO. 

Veo'  .  Extraction  of  part  of  the  capsule  as  an  operative  procedure 

in  certain  cases  of  secondary  cataract.  Arch.  Opth.,  XXII,  p. 
344.     New  York.  ,     .     ,    , 

00,1    Evorsbusch.  Kin   fnll  von  ektopia  lentis  congenita  binoculans  bei 

"^  '  ..inen.  IT  .inhre  alt.  n.anne.  Versa.nuH.lunu-  Deutscher  Natur- 
forscher  u.  Aerxte.     Nurnberg.  ISO.-.. 

29(52.  Fage,  Hemorrhagic  intra-oculaire  grave  apres  une  extraction  de 
cataracte.    Annal.  d'Oculist,  T.  CIX,  p.  266. 

2968.  Faravelli.   Sulla  cataratta  naftalinica.     Annali  di  Ottalm.,   XXU. 

2964.  FreeLd,  Fergus.  On  ten  years"  experience  of  cataract  operations. 

Brit.  Med.  .Tourn.,  May  13. 

2965.  Froniaget,  Cataractes  congenitales  hereditaires  pendant  six  gene- 

rations.     Ibid.,  No.  31. 
2966    Fuchs,  Die  neuen  methoden  der  staar  operationen.     Vortrag  Ge- 

halten  in  der  sitzung  der  k.  k.  Gesellschaft  der  Aerzte  in  Wien, 

December  2,  1892.     Wien.  Klin.  Wochenschrift.  No.  2. 
29(i7.  Galezowski,  Extraction    de    la    cataracte    sans    iridectomie.     Ses 

avantages  et  ses  egueils.    Recueil  d'Opth.     May. 

2968.  GiUet  de  Grandmont,  Observations  de  cataracte  noire.    Extraction. 

Analyze  spectroscopique.    Progres  Medical,  No.  17. 

2969.  Grosz,"E.,  A  szurke  halyog  operalasarol.     (Operation  des  grauen 

staars.)    Szemeszet,  p.  29. 
9970    Gullstrand,  A.,  Ein  fall  von  lenticonus  posterior.     Nordisk  Opthal- 

mologisch  Tidsschrift.  Vol  I.     (Typischer  Fall  von  linksseitigem 

lenticonus  posterior  bei  einem  30  jahringen  Maim.. 
2971    Heucke.  A..  Beitrag  zur  lehre  von  der  aetiologie  uu.l  behandlung 

der  luxationen  der  krystallinse.     Inaug.  Diss.     Strassburg. 

2972.  Hisigens,  C.  Extraction  of  cataract.     Lancet.  II.  p.  1180. 

2973.  Hippel,  E.  v.  sen.,  Ueber  den  gegenwartigen  stand  der  staar  oper- 

ation.    Munch.  Med.  Wochenschr..  S.  669. 

2974.  Hirschberg,    J..    Ueber   schichtstaar   bei    altereu    luenschen.      Cen- 

tralbl.  f.  Prakt.  Augenheilk.,  August.    S.  225. 
•2975.  .   Heilung  der  kurzsiclitigen    netzliautablosunjr    nach    auszei- 

hung  der  getrubten  linse.     Ebd.     Marz. 
2976.  Howe,  L.,  On  the  removal  of  hard  cataract  by  s...tiun.     'I>ans.  of 

the  Amer.  Opth.  Soc.  29th  Meeting,  p.  594. 
0977    .Tackson,  E..    When    cataract    is    ready  for    operativ(>    treatment. 

Trans.  Med.  Soc.  Pennsylvania.  XXIV.  p.  97.     TMula.lelphia. 


554 

1893.    2978.  Jackson.  E.,  Indirect  massage  of  the  lens  for  the  artificial  ripening 
of  cataract.    Trans,  of  the  Amer.  Opth.  Soc,  29th  Meeting,  p.  523. 

2979.  Kayser,  Fritz,    Iridectomy  necessary    twelve    and    fourteen    days 

after  normal   extraction   of   cataract.      Opth.    Record,    Nashville. 
1892-93,  p.  353. 
2970a.  Hess,  Zur  Pathologie  und  Pathologischen  Anat.  verschieden  Staar 
formen.     Graefe  Hich.  f.  Opth..  XXXIX,  1.     1893. 

2980.  Korschenewsky,  S.,  Kurzer  bericht  uber  das  zweite  hundert  von 

katarakt  extractionen  in  der  land  praxis.  (Kratkij  ottschott  o 
•wtoroj  sotne  iswletschenij  katarakti  w  semskoj  praktike.)  Ibid., 
XL,  p.  483. 

2981.  Krukow,   A.,  Ein  fall  von  pyramidal  katarakt.     Sitzungsberichte 

des  Moskauer  Opth.    Vereines.    1892. 

2982.  Kusehew,  N.,  Kurzer  bericht  uber  das  zweite  hundert  von  kata- 

extraktionen  (Kratkij  ottschott  o  perwoj  totne  iswletschenij  kata- 
rakti).    Wjestnik  Opth.,  X,  p.  510. 

2983.  Landolt,  Un  couteau  destine  a  la  discission.     Arch.  d'Opth.,  XIII. 

p.  529. 

2984.  Logetschnikow,  S.,  Eine  eigenartige  katarakt  mit  sequester.    Sitz- 

ungsberichte des  Moskauer  Opth.  Vereins.  1892. 

2985.  ,   Eine  seltene  anomalie  von  linsenstaar  (Redkaja   anomalia 

katarakti).     Chirurgitscheskaja  Lepotis,  III,  No.  4. 

2986.  Maschek,  O  operacyi  zacmy  bez  woyciecia  teczowki.     (Uber  staar 

operation  ohne  iridektomie.)     S.  A.  aus  Przeglad  Lekarski. 

2987.  Magnus,  H.,  Ueber  das  verhalten  von  fremdkoipern  in  der  linsc. 

Centralbl.  f.  Prakt.  Augenheilk..  November    S.  327. 

2988.  Manolescu,  A  propos  de  Textraction  simple  de  la  cataracte.    Rou- 

manie  Med.    Mars. 

2989.  Mastrocinque,  Massagio  diretto  sul  cristallino  per  la  maturazziont- 

artiflciale  della  cataratta  con  un  nuovo  instrumento.  (Rend,  del 
XIII.  Congr.  della  Assoc.  Oftalm.  Ital.)  Annali  di  Ottalm.,  XXII. 
p.  45.  (Empfehlung  der  direkten  linsen  massage  mit  eihem  eige- 
nen  sondenartigen  instrument.) 

2990.  McCoy,  T.  J.,  A  new  shield  for  the  protection  of  eyes  after  cata- 

ract operations.  Med.  Record,  New  York,  1892,  XII,  p.  (;04.  and 
South.  Californa  Pract.,  Los  Angeles,  1892,  VII,  p.  8. 

2991.  Meyer,   E.,   Malformation  du  cristallin.     Revue  Generale  d'Opth.. 

p.  1. 

2992.  Mitvalsky,    Microphakie    und    deren    klini.sche    bedeutung.     Klin. 

Monatsbl.  f.  Augenheilk.,  S.  323. 

2993.  Moerner,  C.  Th.,  Untersuchung  der  proteinsubstanzen  in  den  licht- 

brechenden  medien  des  auges.  (3)  Mitt.  Zeltschr.  f.  Phys.  Cheni.. 
XVIII,  S.  61. 


555 
2JHM.   Moore,   W.  O..  The  after  ticiitiiicut   of  cataiacl    ixiia<-tlon.      Med. 

News,  Philadelphia,  p.  '2'>:',. 
2995.  Mooren,   Die  iiidikationsjin-iizeu  der  caL-iract   discission.    Deutsche 

Med.  Wochenschr.,  S.  857. 
291)(;.  Moorehead.  G.  C,  Cataract  operations,     .lourn.  .\nier.  .M«'d.  Assoc, 

Chicago,  XX,  p.  437. 
29J>7.  Mules,  Pyramidal  cktaract.     lOptli.  Soc  of  the  United  Kiuj^dom.) 

Opth.  Review,  p.  W9. 
2!>5>8.  Murell,  T.  E..  The  simple  dressing  after  cataract  extraction.    Opth. 

Record,  Nashville,  1893-4,  III,  p.  121. 

2999.  Neuburger,  Ueber  die  hauflgkeit  der  staarbildung  in  den  vehschie- 

denen  lebensaltern.     Centralbl.  f.  Prakt.  Augenheilk..  September, 
S.  2(!3.    Beitrag  zur  entwickelung  der  katarakt.     Ebd.,  S.  165. 

3000.  Nicati,  La  pointe  couteaux  a  cataracte.     Facheuse  routine  a  dera- 

ciner.     Arch.  d'Opth.,  XVII,  p.  136. 
.3001.  Nickelsburg.  Leopold,  Weitere  beitrage  zur  aetiologie  der  cataracta 

senilis.     Inaug.  Diss.    Wurzburg,  1892. 
.3002.  Panas,   Prophylaxie  des  accidents  infectieux  consecutifs  a  I'oper- 

ation  de  la  cataracte.     Arch.  dOpth.,  XIII.  p.  593. 

3003.  ,  L'operation  des  cataractes  congeni tales.  Progres  Med.,  No.  7. 

3004.  Parinaud,  Le  prolapsus  de  I'iris  dans  I'extraction  simple  de  la  cata- 

racte.    Soc.  d'Opth.  de  Paris.     April,  1893. 

3005.  Peters.  A.,  Ueber  die  entstehung  des  schichtstaars  und  verwandter 

staarformen.     V.  Graefe's  Arch.,  XXXIX,  1,  S.  221. 

3006.  Piechaud,  A..  Cataracte  congenitale  demi-pierreuse.  Recueil  d'Opth. 

p.  .552. 

3007.  Reche.  A.,  Ein  beitrag  zur  entwickelung  der  katarakt.     Centralbl. 

fur  Prakt.  Augenheilk.,  May.     S.  129. 

.•{008.  -.  Ein  fernerer  beitrag  zur  entwickelung  der  katarakt.     Ebd. 

December.     S.  963. 

3009.  Rivers.  E.  C.  Cataract  extraction.     New  York  Med.  .lourn.,  p.  301. 

3010.  Roethlisberger.  1*..  Ueber  die  ansspulungen  der  vorderen  kammer 

bei  der  staarextraktion  an  der  Easier  Opth.  Klinik.     Inaug.  Diss. 
Basel. 

3011.  Roosa,  .John,  A  series  of  cataract  operations.     Post  Graduate,  New 

York,  VIIL  p.  271. 

3012.  Rudall,  J.  T..  Spontaneous  rupture  of  capsule  after  iridectomy  pre- 

liminary to  cataract  extraction.     (Opth.  Soc.  of  tlie  United  King- 
dom.)   Opth.  Review,  p.  347. 

3013.  Santos  Fernandez.  .1..  Conducta  que  debe  observarse  con  las  cata- 

ractas  invalidas  de  glaucoma.     Cron.  Med.  Quir.  de  la  Habana, 
1892,  XVIII,  p.  740. 

3014. ,  Hernia  voluminosa  del  iris  despues  de  la  extraccion  simply 

de  la  cataracta.     Ibid.,  p.  0. 


556 

1893.    3015.  Sbordoms    Osservazioni   pratiche   sulla  operazione   della   cataratta 

col  processo  a  lembo  seuza  iridectomia.     (Rend,  del  XIII.  Con- 

gresso  della  Assoc.   Oftalm.  Ital.)    Annali  di  Ottalm.,  XXII,  p. 

.^rjJ).     (Siehe  diesf'n  Rev.  pro  1802. > 
3016.  Schantz,  Fritz-Jena.  Ueber  deu  eiufluss  der  pupillaroffuimg-  auf  das 

sehen  aphakischer.     Verhandlungen  der  Gesellschaft  Deutscher 

Naturforscher  u.  Aerzte.     Halle,  1891. 
8017.  Schlosser,   Ueber  akkommodation  aphakischer  augen.     (Gesellsch. 

f.  Morphol.  und  Physiol.)    Munch.  Med.  Wochenschr.,  S.  291. 

3018.  Schoen,  W.,  Die  anfange  und  ursachen  der  stare.    Deutsche  Revue. 

Breslau  u.  Berlin.  XYIII,  S.  115. 

3019.  Die  funktionskrankheiten  d.  auges.     Wiesbaden.    J.  F.  Berg- 
man. 

3020.  Schreiber,   P..    Elfter  jahresbericht    meiner    augenklinik.      .Tahrg. 

1893. 

3021.  Schweigger,  Operative  beseitigung  hochgradigre  myopic.  Deutsche 

Med.  Wochenschr.,  No.  20. 
.3022.  Smith,  and  Travis,  B.  F.,  Report  of  a  case  of  extraction  of  cata- 
ract in  a  negro  said  to  be  116  years  old.     Journ.  Amer.  Assoc, 
Chicago,  XXI,  p.  684. 

3023.  Snell,   S.,   Case  presenting  unusual  appearances  after  extraction; 

simulating  cyst,  but  really  due  to  a  distended  capsule.  Opth. 
Review,  p.  345.  Die  ausgedehnte  eine  cyste  vortauschende  linsen 
kapsel  bei  einer  vor  7  jahre  staaroperierten.  Frau  entheilt  Zer- 
fallsprodukte  der  linse  selbs. 

3024.  Sous,  De  I'uree  apres  les  operations  de  cataracte.     .Journ.  de  Med. 

de  Bordeaux,   September  17. 

3025.  Stafford,   H.   E.,   Extraction  of  senile  cataract.     New  York   Poly- 

clinic, I,  p.  142. 

3026.  Swanzy,  On  the  combined  method  of  cataract  extraction.     (Opth. 

Soc.  of  the  United  Kingdom.)     Opth.  Review,  p.  213. 

3027.  Teale,  T.  P.,  Bowman  lecture  on  the  abandonment  of  iridectomy 

in  the  extraction  of  hard  cataract.  .Journ.  Amer.  Med.  Assoc, 
Chicago,  XXI,  p.  684. 

3028.  Theobald,  S.,  Exhibition  of  patient  with  zonular  cataracts.     John 

Hopkins  Hospital  Bull.,  Baltimore.  IV,  p.  55. 

3029.  Thier,  Die  operative  behandlung  hochstgradiger  myopie  durch  dis- 

cission der  linse.    Deutsche  Med.  Wochenschr.,  XIX,  S.  717. 

3030.  Trousseau,    Le  pterygion  et  I'operation    de    la    cataracte.     Annal 

d'Oculist,  T.  CIX,  p.  146.  (Verf.  glaubt  versichern  zu  mussen, 
dass  ein  vorhandenes  pterygium  nicht  die  Gefahr  der  Eiterung 
nach  einer  staaroperation  erhohe.) 

3031.  Vacher,  M.,  Nouvolle  technique  operatoire  de  la  capsulotomie  dans 

I'operation,  de  la.  cataracte.  Societe  d'Opth.  de  Paris.  Seance 
du  7  Novembre,  1893. 


557 
18it:{      30812.  Yolhagen.   C   Kiii  scll<iic   forin   von  .-iif wicUlmitisslorunp  iind  Ge- 
webswioluM-un.u-  iiu  Iiiiicrii  ("iiu's  TiorMUtrcs.     V.  fJraefe's  Arch.  f. 
Opth.,   XXXIX.  4.   S.  l!21. 

3033.  Valk,  Tr.,  Catanu-t  extraction  with  tlu-  iris  retractor.     (Read  before 

the  section  of  opthalnioloR.v  of  tl..-  first    Pan-American  Medical 
Conirress.)     Am(^r.  .Toiirn.  of  Optli..  p.  300. 

3034.  Vossius.  A..  Zur  Ivasnistilc  der  angeborou  anonialicii  des  auges. 
303r>.   K.Miiscliniann's  Beitrage  zur  Augenhoilkunde.  IX.  Heft. 

3030.   Warner.  A.  (",..  Dislocation  of  tlie  lens  and  subs(>quent  cataract  by 
a  sliot  from  an  air  gun.   .louni.  Optli.  otol.  and  Laryngol.,  V,  p.  88. 

3037.  Webster.   D..  A  case  of  congenital  cataract;  both  lenses  removed 

by  operation.     Arch.  Pediat.,  New  York,  X,  p.  929. 

3038.  DeWecker.   Reminiscences   historiques   concernant   I'extraction   de 

la  cataracte.     Arch.  d'Opth.,  XIII.  p.  212. 

3039.  — .  T.a  section  de  Daviel.     Ibid.  p.  2tn. 

3040.  ,  INIodifications  apportees  par  Daviel  a  la  section.     Ibid,  p.  401. 

3041.  — ,  L'extraction  a  lambeau  triangulaire  ou  ogival.    Ibid,  p.  412. 

3042.  Wescott,  An  unusual  case  of  dislocation  of  the  lens.     Annal.  of 

Opth.  and  Otol.,  January. 

3043.  Wintersteiner.    Ein    fall    von    eiuseitigen,    doppelten    schichstaar. 

Klin.  Monatsbl.  f.  Augenheilkunde.  S.  300. 

3044.  — .   Angularer  aequatorialstaar.    Ebd.,   S.   333. 

3045.  White,  J.  A.,  Cataract;  report  of  100  operations.    Virginia  Medical 

Monthly.  Richmond,  1892-93.  XIX,  p.  731. 
3046    Zimmermann,  C,  Dislocation  of  the  lens  into  the  anterior  cham- 
ber with  iridodialysis;  extraction;  recovery.     Congenital  unilat- 
eral anopthalmus.     Arch,  of  Opth.,  XXII,  No.  3. 
1894.    3047.  Adelheim,  Ein  fall  von  colobomallentis.    Wjest.  Opth.,  XI,  2,  S.  191. 

3048.  Ahlstrom.    G.,   Redogonelse   for   100   staaroperationer.     Goteborg's 

Lakar.  Forh.,  N.  I. 

3049.  Birnbacher,  Ein  neues  verfahren  der  kapselentfernung  bel  staar- 

operationen.     C.  f.  Pr.,  A.,  S.  65. 

3050.  Bitzos,  G..  Le  point  noir  de  I'operation  de  la  cataracte  par  l'ex- 

traction.    Ann.  d'Ocul.,  CXI,  4,  p.  247. 

3051.  Brose.  L.  D..  Two  cases  of  double-sided  ectopia  lentis.     Opth.  Rec. 

IV,  1,  p.  24. 

3052.  Cheatham,  W.,  Cataract  extraction  an  office  extraction.     Ibid,  IV, 

2,  p.  62. 

3053.  Chisolm,  .1.  J.,  Hoav  cataract  patients  eyes  are  dressed  at  the  Pres- 

byterian Eye,   Ear  and  Throat  Charity   Hospital   of   Baltimore, 
Ann.  of  Opth.  and  Otol..  Ill,  1,  p.  5. 

3054.  Chodin.  Ueber  eine  merkwurdige  comiilication  bei  der  cataract  ex- 

extraction.     Wjest.   Opth.,   XI,   S.   78. 
30.55.   Christen.  Th..   Drei  falle  von  angeborenen\   linsen  colobom.    Arch. 
f.  .\ugeiilieilk..  XXIX,  S.  233. 


558 

1894.     3056.  Clark.  C.  F.,  A  case  of  binocular  colobonia  of  the  lens  with  accom- 
modative power  retained.     Trans,  of  tlie  Anier.  ()i)tli.  Soc.  p.  999. 
Dislocation  of  both  crystalline  lenses.     ll)id.  p.  '2'AU. 
3057.  Collins.  Treacher.  The  association  of  lamellar  cataracts  and  il(  kets. 

Opth.  Soc.  of  the  United  Kin.udom.  November  4. 
30.58.   Czermak.  \V..  rel)er  druckende  verbandc  nnd  wundsprengung  nach 
staar  extraction.     Wiener  Klin.  Woclienschr..  VII.  No.  27.  S.  506. 
Ueber  extraction  ohne  iridectomie.     Ibid,  No.  27. 

3059.  Dalganow.  T'el)er  den  astigmatismns  der  liornhant  nach  cataract 

extraction.     W.1est.  Optli.,  NI,  1.  S.  IS. 

3060.  Dehn.  E.,  Ein  beitrag  zur  kentuiss  der  luxtaio  lentis.     A.  f.  O..  XL. 

S.  237. 

3061.  Derby.  Hasket,  Hipts  concerning  the  performance  of  the  operation 

for  the  extraction  of  senile  cataract,  being  a  record  of  personal 
experience.    Boston  Med.  and  Surg.  Journ.,  CXXXII.  No.  5.  p.  97. 

3062.  Dimmer,  Das  opthalmoscopische  aussehen  des  linsenrandes.    Wien. 

Klin.  Wochenschr.,  No.  46-47. 

3063.  Dolard.    Considerations   generales   sur   I'operation   de   la    cataracte 

ches  enfants.    Rec.  d'Opth.,  No.  8,  p.  468. 

3064.  Dolganoff,  W.,  Ueber  die  veranderungen  des  wudastigmatismus  der 

hornhaut  nach  der  cataract  extraction.  Arch.  f.  Augenheilkunde. 
XXIX,  S.  13. 

3065.  Dolganow,    Ueber    corneal    astigmatismns    nach    staar    operation. 

Wjest.  Opth.,  No.  4,  S.  388. 

3066.  Erwin,  A.  J.,  Two  lenses  extracted  from  one  eye  at  the  same  sitting. 

Opth.  Rec.  Ill,  11,  p.  433. 

3067.  Page,  Le,  Le  nettoyage  secondaire  de  la  pupille  dans  les  operations 

de  la  cataracte  trauma tique.  Inter.  Med.  Congr..  XL  L'extrac- 
tion  simple  de  la  cataracte  sur  les  yeux  atropinisees.  Soc.  Franc. 
d'Opth. 

3068.  Field  le  Mond.  R..  Cataract  operation  and  office  operation.     Opth. 

Rec,  IV.  2,  p.  72. 

3069.  Fox.  L.  W..  Immediate  capsulotomy  following  the  removal  of  cata- 

ract.    Journ.  Amer.  Med.  Assoc,  June  2. 

3070.  Oasperini.  E.,  Emmoragia  consecutiva  ad  ablazione  di  cataratta  e 

successiva  guarigione  sponatanea  di  ambo  gli  occhi.  Annal.  di 
Ottal.,  XXIII,  p.  270. 

3071.  Gifford,  IL,  The  shield  dressing  for  cataract  extraction.     Ann.  of 

Opth.  and  Otol.,  Ill,  2,  p.  141. 

3072.  Goerlitz.  M..  Beitrage  zur  pathologischen  anatomic  der  cataracta 

diabetica.     In.  Diss.    Freiburg. 

3073.  Graddy.  L.  B..  The  prevention  or  modification  of  astigmatism  after 

cataract  extraction.    Opth.  Rec,  IV,  1.  p.  1. 

3074.  Ilaltenhoff,   Traitement  de  cataractes   traumMti(iues.      Soc.    Franc. 

d'Optli. 


559 

18!»4.     aoir,.   Mc-llardy.  Tlu-  :.r1ili<iMl  lu.-minitinii  ..f  i.unmiur-  s.-nil.-  cataraft  by 

trituraticM.  altrr  tlic  nictli<Ml  of  ImmmsI.t.     Tvaus.   Inirniai.  Oi-th. 

Conjjr..  p.  '^T(t. 

307(!.   Harlan.    11..   Tlu-  i.last.T  strii.  .-ataract   dn-ssin-.    n.-u    ami   .v.>l   ..Id. 

Opth.  Ki'C,  111.  11.  !••  4:{1. 

3077.  noc'(inart.   K..    D.^rnniiatioiis   nH'(liaiii.iii«'s   <iu    .lisialliii    dans    l.-s 

yeux  pathol()jii«iU(«s.     Anli.  dOi.lli..  XIN'.   1.  i-.  l'<)<.t. 

3078.  Jackson.   E..  Astijiinatism   followiii;;-  catarad   .".\1r:icl  ion   aiul   other 

sections  of  the  corn. 'a.  OpHi.  U.-...  III.  11.  p.  to'.t.  n.'slni.li.m 
of  the  eye  by  hcin..rrlia;;f.  r.dl.>\vinj;  .alara.-l  .-xtraction.  Ann. 
of  Opth.  and  Otol.,   111.  1.  i'.  '••■ 

3079.  .Tolks.  L.  B..  Report  of  cataract  op.-ralion  in  tli.-  .-is.-  .>f  three  sis- 

teis.     Opth.  Rec,  IV.  2.  p.  CS. 

3080.  Kalt.    De  la   suture  corneenne  aprcs   rcxna.ii.>ii   .h'    la    (ataraete. 

Arch,  of  Opth..  XIV.  10.  p.  r,:\U.  lUe  coruealnaht  na.h  extra,  tion 
des  cataract.     Arch.  f.  Au.iienli..  XXX,  S.  15. 

3081.  Kessler.   11.   M.   V..  Tranniatischc  spli.jtinu   (Wv  lens.     Oogh.   Versl. 

Utrecht. 

3082.  Knapp,   II..   Remarks  on   the  extraction  of  cataract,   based  on  the 

results  of  the  operations  of  tiOO  consecutive  cases.  Trans.  Intern. 
Opth.  Congr.,  p.  14. 

.3083.  Lawford.  .1.  B..  Peculiar  cataracts  of  lamellar  ty|.es.  Trans.  Opth. 
Soc.  XIV,  p.  138. 

.3084.  Lippencott,  J.  A.,  Unusually  large  loss  of  vitreous  in  cataract  ox- 
traction;  recovery  with  useful  vision.  Trans,  of  the  Amer.  Opth. 
Soc,  p.  252. 

3085.  Little.  D..  Extraction  of  senile  cataract,   with  and    without   iridec- 

tomy; live  years"  hospital  experience.  Trans.  Internat.  ()i>tli. 
Congr.,  p.  25. 

3086.  Logetschuikow,  Ueber  die  einfache  extraction  des  cataract  anf  dem 

atropinisirten  auge.    Wjest.  Opth.  XI.  2,  p.  103. 

3087.  Lowe,  J.  W.  C  Cataract  extraction  an  otfice  operation.    Opth.  Rec. 

IV,  6,  p.  213. 

3088.  Marple,  V^'.  B..  Coloboma  lentis.     .\ew  York  Eye  and  Ear  Intirmary 

Rep.,  Vol.  II.  p.  30. 

3089.  Millingen,  van.  Ni'ue  versuch«-  ul)er  die  kt'ratoplastik  und  nber  die 

massregein,  um  den  irisvorfall  nacli  der  einfaclien  cataract  oper- 
ation zu  vermeiden.     Intern.  Med.  Congr..  XI. 

3090.  Mitchell.   S..   Cataract  extraction   an   otfice   .)peration.     Opth.   Rec. 

IV,  1,  p.  7. 

3091.  Mooren.  A..  Die  operative  behandlung  der  natmich   und  kunstlich 

gereiften  staarformen.     Wiesbaden.     Bergniann. 

3092.  Moores  Ball,  J.,  Two  cases  of  traumatic  cataract  in  .hildren.    Ther. 

Gazette.  XVIII,  10,  p.  013. 


56o 

1894.     3093.   Mullcr.  L.,  Hat  der  lenticoiius  sfiiu'u  .liiuiul  in  cinci-  aiKjiii.ilie  der 
hinteron  linsenflache?    Klin.  Mon.  Bl.,  XXXII,  S.  173. 

3094.  Nicati,  M.,  Discissions  cristaliniennes  et  iritomies  ou  couteau.    Ann. 

d'Ocul..  CXII,  p.  398. 

3095.  Nicolulvin,  Berieht  uber  204  cataract  operationeu  in  der  land  praxis. 

Wjest.  Opth.,  XI,  3.  p.  245. 

3096.  Pagensteclier,  H..  Practisclie  rathschlago  zur  staar  operation  fur 

angehende  angeuarzte.    Klin.  Mon.  f.  Augenh.,  XXXII,  S.  339. 

3097.  Peters,  A.,  Ueber  die  entstehung  des  schichtstaares.    A.  f.  O.,  LXX, 

3,  p.  283. 

3098.  Purtscher,    O..    Casuistischer  beitrag   zur  leliro   vom   schielitstaar. 

C.  f.  Pr.,  A..  February,  S.  33. 

3099.  Risley,   S.   D.,   Destructive  hemorrhage  during  extraction  of  cata- 

ract.    Ann.  of  Opth.  and  Otol.,  Ill,  1,  p.  16. 

3100.  Schramm.  F.,   Spontane  aufsaugnng  eines  alterstaares  bel  unver- 

letzter  linsenkapsel.     Wiener  Klin.  Wochenschr.,  No.  37. 

3101.  Schweinitz.  Jackson,  Risley,  Complications  of  cataract  extractions 

and  subsequent  healing.     Opth.  Rec.  Ill,  1,  p.  421. 

3102.  Schweinitz,  G.  E.,  A  case  of  intraocular  hemorrhage  after  extrac- 

tion of  cataract.     Ann.  of  Opth..  January.  April. 

3103.  Snell,  S..  Case  presenting  unusual  appearances  after  extraction  of 

cataract.     Trans.  Opth.  Soc,  XIY.  p.  135. 

3104.  Tenant,  F.,  L'operation  de  la  cataracte  simplifiee  procede  du  Dr. 

A.  Trousseaux.     These,  de  Paris. 

3105.  Theobald,  S.,  A  case  of  panopthalmitis  .suppurativa  following  dis- 

cission of  a  capsular  opacity.    Amer.  Jouru.  of  Opth.,  XI,  7,  p.  193. 

3106.  Terson,  A.,  Sur  la  pathogenie  et  la  prophylaxie  de  I'hemorrhagie 

expulsive  apres  I'extraction  de  la  cataracte.  Arch.  d'Opth..  XIV, 
2,  p.  110. 

3107.  Thompson.   L.,   Observations  on  some  phases  of  opacity  and  lux- 

ation of  the  crystalline  lens.     Brit.  Med.  .Tourn..  No.  1759,  p.  589. 

3108.  Vullers.  H..  Angeborene  cataract  beider  augen  niit  perforation  der 

linsenkapsel  beim  kaninchera.    A.  f.  O..  XL,  .">,  S.  190. 

3109.  Weeks,  J.  E.,  A  case  of  lenticonus  posterior,  witli  remarks.     Arch. 

of  Opth.,  XX,  2,  p.  260. 

3110.  Wiclierkiewicz,  Febfler  die  behandlung  intraocularer  eiterung  nach 

staar  operationen.     Wiener  Klin.  Wochenschr..  No.  46-47. 

3111.  Wolkow,  1st  die  kapsulotomie  bei  der  extraction  seniler  cataracte 

nothwendig?    Ibid.,  No.  4.  S.  36(>. 

3112.  Abadie,  Rapport  sur  un  travail  de  M.  Ic  Dr.  Bistls  (de  Constanti- 

nople), intitule  de  la  cataracte  par  rajtport  aux  convulsions.  Un 
cas  de  tclanie  avec  cataracte  mollc.  Societe  d'Opth.  de  Paris. 
Marcli. 


56 1 
1894:.     3113.  Albraud.  W..  Report  of  ~)4\)  futaracts  oitci-atcd  at    I'rof.  Scboclcr's 
eye  clinic  in  Berlin.     Arch,  of  Oplli..  XXTII.  i..  1.V'..    Oki.  (sicbe 
diesen),  Ber..  1898,  S.  292. 

3114.  Ball.  J.  M.,  Two  cases  of  traumatic  cataract  in  ciiildrcn;  siucess- 

fiil  results.    Therap.  Gaz.,  Detroit,  X.  p.  G61. 

3115.  Barrett,  J.  W.,  Foreign  body  in  lens;  traumatic  cataract;  extrac- 

tion of  foreign  body  and  lens  in  globe.    Austral.  Med.  Journ.,  Mel- 
bourne, XVI,  p.  157. 

3116.  ,  A  case  of  couching  for  catarad:  pfrfcct  vision  tliirteen  years 

afterwards.    Ibid,  p.  381. 

3117.  Bei'ceot,   H.,   Quelques  considerations   sur  le   traitement  des  cata- 

ractes  secondaires.     Tliese.  de  Pari.^;.     (Bringt  Bekanntes.) 

3118.  ,  A  propos  de  I'operation  de  Daviel.     Ibid.  p.  2.57. 

3119.  Bourgeois,  Lunettes  pour  operes  de  cataracte.     (Societe  Francaise 

d'Opth.)    Recueil  d'Opth.,  p.  39(i. 

3120.  .  Procede  simple  pour  certaines  extractions  dans  la  chanibre 

anterieure.     Ibid,  p.  286. 

3121.  Chand,  M.,  Spontaneous  falling  down  of  cataract  into  the  posterior 

chamber;  restoration  of  sight.  Med.  Reporter,  Calcutta,  IV,  p.  140. 

3122.  Chibret.    Un  cas  de  correction   astigmatique  du   crlstallin.     Arch. 

d'Opth.,  XIV,  p.  275.  ■ 

3123.  ,  On  the  good  effects  of  dressing  one  eye  only  after  cataract 

extractions.     Brit.  Med.  Assoc,  62d  Meeting.    Bristol. 

3124.  Cirincione,   Cataratta  lussata  nella  camera  anteriore  e  glaucoma 

consecutivo.    Riforma  Med.,  Napoli,  II.  p.  220. 

3125.  Collins,  W.  J.,  Note  on  non-pathological  cataracts.  Lancet,  I,  p.  1493. 

3126.  ,  Ueber  druckende  verbande  und  wundsprengung  nach  staar- 

extraktion.    Bbd.,  p.  506. 

3127.  Schweinitz,  de,  A  case  of  intraocular  hemorrliage  after  extraction 

of  cataract.    Amer.  Opth.  and  Otol.,  St.  Louis,  III,  p.  12. 

3128.  ,  The  treatment  of  immature  cataract,  and  when  to  operate 

for  cataract.     Journ.  Amer.  Med.  Assoc,  Chicago,  XXII,  p.  105. 

3129.  Danesi,  G.,  La  medicatura  antisettica  nella  chirurgia  oculare.    Boll. 

d'OcuL,  XVI,  13. 

3130.  Dolard,  De  la  cataracte  chez  les  jeunes  sujets.   These,  de  Paris. 

3131.  Donberg.   G.,   Ueber  aseptik  bei  augen  operationen.   (Ob  aseptike 

pri  glasnich  operatijaeh.)   (V.  Kongr.  d.  Russ.  Aerzte  in  St.  Peters- 
burg.)   Wjestnik  Opth.,  XI,  i».  7H. 

3132.  Dujardin,  A  propos  de  I'operation  de  Daviel.    Annal.  d'Oculist,  T. 

CXI,  p.  258. 

3133.  Dunn,  Vacuoles  de  crlstallin.     Virginia  Med.  Monthly.  August. 

3134.  Egappa,  T.  A.,  A  modified  operation  for  extraction  of  cataract  se- 

nilis.    Indian  Med.  Record,  Calcutta.  1893,  V.  p.  313. 


562 

1894.    3135.  E]gbert.  J.  H..  The  absorption  of  immature  cataract  with  restoration 

of  vision.     Paoitic  Med.  and  Surg.  Record,  San  Francisco.  1893-94, 

VIII.  p.  147. 

3136.  Erwin,  Two  lenses  extracted  from  the  same  eye  at  the  same  sitting. 

Opth.  Record,  May. 

3137.  ,    Soixante-dix    extractions    de    cataraete;    operations    secon- 

daires.    Gaz.  Med.  de  Picardie,  Amiens.  XII,  p.  43. 

313S.  Fergus.  Patients  upon  whom  the  operations  of  extraction  of  the 
lens  had  been  performed  for  high  degrees  of  myopia.  Olasgow 
Med.  Journal.  XII.  ]).  14(1. 

31.30.  Ferguson.  Lindo  H..  A  new  form  of  capsular  scissors.  Optli.  Re- 
view, p.  58. 

3140.  Fukala.  Beitrag  zur  geschichte  des  operativen  beliandlung  der  my- 

opia.   Arch.  f.  Augenheilk..  XXIX.  S.  42. 

3141.  .  Correction    hochgrider    myopie    durch    aphakic.    Wahl    des 

operations  verfahrens.  mit  rucksicht  auf  die  path,  anatoralschen 
veranderungen  der  choroidea.  Trans,  of  the  Seventh  Internat. 
Opth.  Congress.  Edinburgh,  p.  181. 

3142.  Ilefiebower.    Foreign    bodies    in    the    crystalline    lens.      Cincinnati 

Lancet-Clinic.  February  10.1 

3143.  Heuse,  Einiges  uber  die  ausziehung  des  alterstaares.     Festschr.  z. 

Feier  des  50  jahr.  Jubilaums  des  Vereins  d.  Aerzte  des  Reg. 
Bezirkes  Dusseldorf,  S.  302. 

3144.  Hippel,  A.  v..  Ueber  die  operative  behandluug  hochgradiger  kurz- 

sichtigkeit.     (Naturhistor.   Med.   Vereiu  zu   Heidelberg.)    Munch. 

Med.  Wochensehr..  S.  157  u.  660. 
.3145.  Hirschberg.   Remarques  sur  I'historique  de  I'operation  de  Daviel. 

Arch.  d'Opth.,  XIV.  p.  208. 
3146.  ,  Ueber  den  staarstich  der  Inder.  Centralbl.  f.  Prakt.  Augenh., 

February,  S.  48. 
31^".  .  On  the  cataract  pricking  of  the  Hindus.     Indian  Med.  Gaz.. 

Calcutta,  XXIX,  p.  211. 
3148.  Hori,  M.,  Beitrag  zur  operativen  behaudlung  der  hochgradigen  my- 
opie.   Arch.  f.  Augenheilk.,  XXIX,  S.  142. 
3149. ,  Indirect  massage  of  the  lens  for  the  artificial  ripening  of 

cataract.     Therap.  Gaz..  January. 

3150.  Jackson,  E.,  and  Risley.  S.  D..  Complication  of  cataract  extraction 

and  subsequent  li(>aling.  Opth.  R(>cord,  Nashville,  1893-94.  Ill, 
p.  421. 

3151.  Jennings.  L.  K.,  Report  of  a  cataract  operation  in  tlie  case  of  three 

sisters.     Opth.  Record,  Nashville,  1894-95,  IV,  p.  68. 

3152.  Jennings,  J.  E.,  Remarks  on  the  treatment  of  two  cases  of  lamellar 

cataract.     Med.  Review,  St.  Louis.  XXIX.  p.  285. 


563 

18t)4.     3153. .  On  tlu'  foriiciil  siituic  in  cMtMiacl  .'X  tract  ion.     TraDslatcd  J).v 

II.  KnaiH).    Arch,  of  Upth..  XXIII,  p.  421. 

3154.  Keiper,  G.   F.,   Imniediato  eapsulotomy   following,'  the  removal  of 

cataract.     Annal.  Opth.  and  Otol.,  St.  Louis,  III,  p.  420. 

3155.  Kirk.  R.,  Extraction  of  a  cataract  in  a  niyxoedematous  subject  aged 

72  years.     Lancet,  II.  p.  794. 
315(!.  Knapp.  Ueber  glaucom  nacli  discission  des  naclistaars  nnd  seine 
heilung.     Arch.  f.  Augenheilli.,  XXX,  S.  1. 

3157.  Lang,  Krystallbildung  in  d.M-  linse.     Optli.  Soc.  of  tiie  United  King- 

dom,  November. 

3158.  Langenecker,    D.    F..    lleuiorrliage   after   cataract    extraction,    and 

some  thoughts  as  to  cause.     Proceedings  Kansas  Med.  Soc.  To- 
peka,  p.  291. 

3159.  Ljubornudrow,  14  augenoperationen,  im  lokallazaretii  zu  Lurzk,  in 

den   .Tahren   1892-93  ausgefuhrt.      Wojenno.    Med.   .Tourn..    April. 
(14  extraktionen.  1   Verlust  durch  Panopthalmie.) 

3160.  Manz,  Ueber  operative  behandlung  hochgradiger  myopie.    (Verein 

Freiburger  Aerzte.)     Munch.  Med.  Wochenschr..  S.  1044. 

3161.  Martin,  G.,  Sur  le  delire  consecutif  a  I'operation  de  la  cataracte. 

Communication  faite  a  la  Societe  de  Medicine  de  Bordeaux,  April 
15,  22,  29,  et  May  6. 

3162.  Meigham,  T.  S.,  Extraction  of  the  lens  for  high  degrees  of  myopie. 

Glasgow  Med.  .Tournal,  p.  168. 

3163.  Milanitsch.    P..    Zwei   hundert    katarakt    operationen   Im    kranken- 

hause  der  Stadt  Cetinje  (Dwe  sotni  operatij  katarakti  w  bolnitze 
goroda  Zetinje).     Medizinskoje.  LXII,  p.  583. 

3164.  Neve.  E.  F..  An  analysis  of  two  hundred  cases  of  cataract  extrac- 

tion.    Edinb.  Med.  .lourn..  1894-95.  p.  438.  . 

3165.  Noyes,  The  formation  of  a  central  pupil  by  excision  in  cases  of 

occlusion  with  aphakia.  Trans,  of  the  Seventh  Internat.  Opth. 
Congress.  Edinburgh,  p.  190. 

3166.  ,  Clinical  contributions.     New  York  Eye  and  Ear  Infirmary 

Reports,  Vol.  II.  .January. 

3167.  Pinckhard.    C.    P..    Congenital    ectopia    lentis.      :Medical    Standard. 

Chicago,  XV,  p.  33. 

3168.  Pfluger,  Die  behandlung  der  myopie  durch  discission  der  durch- 

sichtigen  linse.     Internat.  Congress  zu  Rom..  XI. 

3169.  Raineri.  A.,   Cataratta  capsulare  traumatica   con  estese  aderenze 

iridee;  corilisi  con  un  nuova  sinechiotoma  e  consecutiva  espor- 
tazione  della  capsula;  guargione  con  visione  distinta.  Gaz.  Med. 
Cremonese,  Cremona.  XIV.  p.  14. 

3170.  Ripault  et  A.   Guepin,   Diagnostic  des  cataractes.     Gaz.   Med.   de 

Paris.  XVII,  p.  7.3. 


564 

1894.     3171.  Rohmer,  Les  cataractes  tiaumatiques.     Rt^vue  Med.  de  I'Est,  April 
1.    (Nichts  Neues.) 

3172.  Roy,   D.,   Detachment  of  retina   following   a   simple  extraction   of 

cataract.     Refractionist.  Boston.   I,  p.  90. 

3173.  Scliiotz,  H.,  Vorbereitende  behandlung  bei  staaroperationen.  Norsk. 

Magaz.,  No.  4,  iind  Yerhandl.  d.  Med.  Oselllsch.,  S.  30. 

3174.  Scbneideman,   T.    B.,    Spontaneous   resorption   of  cataract.     Pliila. 

Polyclinic,   III,   p.   334. 

3175.  Schneldeman.  T.  B..  A  case  of  spontaneous  resorption  of  a  cataract 

lens.    Amer.  .Tourn.  of  Optli..  p.  1~>2. 

3176.  Schroder.  Dr.  Tli.  v..  Feber  die  bislierigen  resultate  der  operativen 

behandluug  der  hochgradigen  ruyopie  nebst  bemerkungen  uber 
die  antiseptik  bei  augeuoperatione.  St.  Petersburg  Med.  Woch- 
enschr.,   S.  34. 

3177.  Schroder,  Ueber  die  resultate  der  operativen  behandluug  hochgra- 

diger  myopie  durch  extraktiou  der  durchsichtigen  linse  (O  re- 
sultatach  operationawo  letschenja  wisokioh  stepenej  blisorukosti 
posredstwom  iswletschen.ia  prosratschnawo  chrustalika).  Westnik 
Opth..   XI.   S.   101. 

3178.  ,  Die  operative  behandluug  der  hochgradigen  Kurzsiohtigkeit 

mittels  entfornung  der  linse.  Aerztl.  Centr.  Anzeig.  Wien..  VI. 
S.  37,  54. 

3179.  Simi,   A.,   Discorso  intorno  'all  operazione  della  cataratta.     Boll. 

d'Ocul.,  XVI,  1,  2,  3,  5.  (Die  einfache  extraktiou  ist  als  methode 
vox'zuziehen.) 

3180.  Smith,  E.,  Cataract;  morphine  hypodermically.  as  a  means  to  pre- 

vent prolapse  of  the  iris  in  simple  extraction.  Arch.  Opth..  XXIII, 
p.  85. 

3181.  Snellen  (senior),  Traitement  post-operatoire  de  la  cataracte.     (So- 

ciete  Nederl.  d'Opth.)    Aunal.  d'Oculist,  T.  CXI,  p.  137. 

3182.  Stafford.  H.  E.,  The  extraction  of  clear  lenses  for  myopia;  report  of 

tive  cases.  South.  Med.  Record.  Atlanta.  XXIV.  p.  296.  and  New- 
York  Polyclinic.  III.  p.  172. 

3183.  Swett,  N.   M.,   Delirium  and  death   following  cataract  extraction. 

Occidental  Med.  Times,  Sacramento,  VIII,  p.  655. 

3184.  Tenant,    L'operation  de   la   cataracte   simplitiee.      Procede   du    Dr. 

Trous.seau.     These,  de  Paris. 

3185.  Terson.  A..  Sur  la  pathogenie  et  la  prophylaxie  de  I'hemorrhagie 

expulsive  api-es  I'extraction  de  la  cataracte.  Arch.  d"Opth..  XIV. 
p.  110. 

3186.  Theobald.   An   unusual  anomaly  of   tlie  crystalline  lens,   coloboma 

lentis.     Johns  lloi)kins  llosp.  Bullet.,  Baltimore,  V.  p.  52. 

3187.  ,  A  case  of  panopthalmitis  suppurative,  following  discission 

of  a  capsular  opacity.  Amer.  .Tourn.  of  Opth.,  p.  193.  (Opthalmia 
suppurativa  nach  discission  ciner  kapselkatarakt.) 


565 
185t4.    3188.  Thicr.  Bcoi.aclitunjifii  uhcr  opcriUive  korrcktion  dcf  uiyopie.  Trans, 
of  the  Interuat.  Opth.  Congress.  I<:cliuburgh.  p.  173. 

318i>.  .  Zur  operativeu  korrektiou  tier  liochstgradiKon  uiyopie  durch 

discission  dor  linse.     Wieu.  Klin.  Wochenschr.,  VII,  S.  399. 

3190.  Thompson,  I..  L..  Observations  on  sonu'  i)liases  of  opacity  and  on 

luxation  of  tlio  crystalline  lens.     Opth.  Itevicw.  p.  31.^  and  Brit. 
Med.  .Tourn..  II.  !>.  •"'.SO. 

3191.  Titfaiiy.   V.   H..  Cataract.     Interuat.  ("lin..   I'iiila..   III.  s.   IV,  p.  27G. 

3192.  Treacher,  Collins.  L.iniellar  cat.ir.ict  and  rickets.     (Opth.  Soc.  of  the 

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3193.  Tyner.  Austin,  rraliniinatorische  capsulotoinie  hei  der  staaropera- 

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3194.  Vacher,   De   Textractiou   du    crislallin    transparent    comme    raoyen 

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3197.  Vanderbergh,  Un  cas  de  Toperation  de  cataracte  cougenitale.  Presse 

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3198.  Verghese,  V.,  Further  observations  on  the  modilied  operation  for 

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3199.  Viguier,    Contribution    al'etude   de   I'anatomie    pathologique   de   la 

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3200.  Wallace,   J.,    The   microscopical   anatomy   of   the   crystalline   lens. 

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3201.  Walter,   O.,  Ueber  die  gegenwartige  lage  der  frage  uber  die  ex- 

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3202.  Weeks,  C.  .!.,  An  unusual  cas«>  of  I'xt faction  of  the  crystalline  lens. 

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3203.  Wicherkiewicz,  Zur  nachbehundluug  staaroperierter  be!  eingetret- 

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;i204.  AVidmark,    .!.,    Ueber   correction    von    myopie   excessiva    dtu'ch    ex- 

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566 

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3227.  Lowe,  J.  W.  C,  Cataract  extraction  an  ottice  operation.    Sometimes 

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3241.  Riedel.  Max.  Ein  fall  von  traumatischer  linsen  luxation  in  die  pu- 

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matique  partielle  a  la  suite  de  la  penetration  d'un  eclat  de  fer 
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3243.  Randolph.   Robert.  Two  successful  cataract  operations  on  a  dog. 

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3244.  Sym,  AVilliam  George,  A  case  of  lenticonus  posterior.     Opth.  Rev.. 

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3245.  Schneideman.  T.  B..  Note  upon  a  condition  of  the  pupil  following 

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3247.  Tennant.  Frederic,   L'operation  de  la  cataracte  simplifiee  procede 

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3248.  True,    Des   manifestations   generales   et   refringentes   du   globe   de 

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3249.  WicherkieAvicz.  BoL.  Zur  nachbehandlung  staaroperirter  nach  ein- 

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3261.  Cartwright,  Posterior  lental  opacity;  remains  of  hyaloid  artery  and 

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3262.  Cramer,    Ein   fall   von   lonticonus   posterior.      Klin.    Monatsbl.    fur 

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3276.  Gunn,  R.  Marcus,  Peculiar  corraliform  cataract  with  crystals  (  ?  of 

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3277.  Gradenigo,   Pietro,    Sull'   estrazione  capsulo-lenticolare  della  cata- 

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3278.  Ginsberg.  Ueber  die  angeborenen  colobome  des  augapfels.     (Nach 

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3279.  Grosser,  Paul,  I'eber  ectopic  lentis.     Inaug.  Dissert.    Berlin,  1896. 

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3305.  Schoen,  Wilhelm,  Die  staarkrankheit,  ihre  ursache  und  verhutung. 

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:!;i07.  Thomas,  Wilhelm,  Beitrag  zur  lehre  von  der  cataracta  diabetica. 
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3308.  Trotow,  Otto,  Operazione  delle  cataratte  incomplete.  Ann.  di 
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•i.'lc 

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i.  l.SfK;.     De  l-extrac- 

(lyrll 

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3312.  Wood,  Casey  A.,  The  after  treatment  of  normal  cataract  extrac- 

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3314.  Weill,  George,  Aiguilles  lancettes  pour  U'.s  opcnilions  de  cataracte 

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3318.  Davis,  A.  Edward.  The  report  of  a  case  of  double  senile  cataract, 

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3332.  Critchett,  Anderson,  Extraction  of  dislocated  lens  with  good  result. 

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3333.  Coover,  David.  An  interesting  but  disastrous  termination  of  a  cata- 

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575 

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.    Vol. 

XIV. 

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ithali: 

11..  No. 

18J»7.  3.380.  Elnior,  .Mitlliciliui.u  nlx'i'  t(Mi  cxltai 
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(Icr  riiivcrsilats  Aii,i:riikliiiik  /.i 
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3347.  Jackson,  Edward,  The  location  of  opacities  near  the  posterior  pole 

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3348.  Jenckel,   Adolf,   Ein  fall   von  luxatio  lentis  iiiit   acuteiii   gl.iiikoni. 

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3350.  Lange,  O.,  Zur  frage  der  spontanen  intracapsulareu  resoiption  der 

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3352.  Moulton,  H.,  A  case  of  cataract  extraction  under  discouraging  con- 

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3370.  Schlodtmann.   \Valt<'r,    Teller  eineni   fall   von   liixaiion  der  linse  in 

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V.  Graefe's  Arcli.  f.  Optlialm..  Bd.  XLIV,  1.  p.  127. 

3371.  Snellen,   H..   Erythropsie.     A.   v.   fJraefe's  Arch.   f.   Opthalm.,   Bd. 

XLIY,  1,  p.  10. 

.3372.  Schauz,  Fritz,  Eiue  familie  luit  jnvcuilor  katarakt.  Centralbl.  f. 
Prakt.  Augonheilk.,  p.  2G4.     September. 

.3373.  Thomson,  I'hiladelphia.  Section  of  Opthalmology.  College  of  Phy- 
sicians of  Philadelphia,  February  10.  1S97.  Case  of  foreign  body 
in  the  leus. 

3374.  Yertiz,  America.  Report  of  the  Section  of  Upthalniology,  Pan- 
American  Medical  Congress,  held  at  Mexico  City,  November,  1896. 
A  new  operation  for  cataract.  American  Journal  of  Opthalm.. 
Vol.  XIV,  No.  1,  p.  17. 

337.5.  Walter,  O.,  Zur  casuistik  der  operirten  angeborenen  staare.  Klin- 
ische  Beobachtung.)   Centralbl.  f.  Prakt.  Augen.,  p.  364.  December 

3376.  Wolff,  Ueber  regeneration  der  exstirpirten  linse  beim  Triton.    Sit- 

zungsber.  d.  Wurzburger  Phys.  ^led.  Gesellschaft,  p.  59.    1896. 

3377.  White,  Joseph  A.,   So-called  accommodation   in  the  lenseless  eye. 

Opthalm.  Recoi-d,  Vol.  VI,  No.  9.  p.  487. 

3378.  Chibret,  Paul,  Le  lavage  de  la  chambre  posterieure  apres  I'oper- 

ation  de  la  cataracte.    Arch.  d'Opthalm.,  T.  XVII,  No.  9,  p.  545. 

3379.  Demicheri,    L.,    Anneaux    d'interference    du    cristallin    cataracte. 

Arch.  d'Opthalm..  T.  XVII,  No.  1,  p.  38. 
1898.    3380.  Coover.  D.  H..  An  interesting  but  disastrous  termination  of  a  cata- 
ract operation.     Opth.  Record,  March.  1897. 
3.381.  Chibret,  Lavage  of  the  posterior  chamber  after  cataract  extraction. 

Arch.  d'Opth.,  XVII,  p.  545. 
3382.  Bach,  L.,  A  contrilnition  to  the  liistology  and  genesis  of  lenticouus 

posterioi-.     Arch.  f.  Augenh..  XXXYI,  p.  161.     Pathologisch  anat- 

omische    studien  uber    verschiedene    missbildungen    des    auges. 

Graefe's  Arch.,  Bd.  XLV,  Part  I. 
,3.383.  Bloom,  S.,  Uber  die  retro-choroideal  blutungen  nach  staar  extrac- 

tionen.     Graefe's  Arch.,  Bd.  XLVI,  Part  I,  p.  184. 
3384.  Baeck,  S.,  Experimentelle  histologische  untersuchungen  uber  con- 

tnsid  bulbi.     Bd.  XLVII,  Part  I,  p.  82. 
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Ann.  di  Ottalm..   XXXVI,   1-2.   p.   70. 
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578 


3387.  Back,  Histology  and  development  of  lenticonus  posterior.    Arch, 
f.  Augenheilk.,  XXXVI,  1-2. 

3388.  Borthen,   Johann,   The  open  wound   treatment  for  cataract  oper- 

ation.    Klin.  Mouatsbl.  f.  Augenheilkunde.    August,  1898. 

3389.  Demicheri,  Posterior  polar  cataract  and  lenticonus.   Nederlandische 

Ooghselk.  Bydragen.  Afl.,  3,  41.    1897. 

3390.  DeSchweinitz,   Glaucoma  three  years  after  extraction  of  cataract 

by  combined  method.     Opth.  Record.     December,  1897. 

3391.  Distler,  Contribution  to  operations  on  senile  cataract.    Festschrift 

d.  Stuttgarter  Aerztl.  Vereins.    1897. 

3392.  Dunn,  A  case  of  ossification  of  the  lens.     Pathology  by  Ward  Hol- 

den.    Arch.  f.  Opth.,  Vol  XXVII,  5,  p.  500. 

3393.  Freyer,  The  technique  of  cataract  extraction.     Amer.  .lournal  of 

Opth.,  July,  1897. 

3394.  Fernandez,  Santos,  Cataract  operations.    Ann.  d'Opth..  Vol.  I,  No.  1. 

July,  1898. 

3395.  Frenkel,  Henri,  Researches  into  the  renal  permeability  in  the  case 

of  those  suffering  from  senile  cataract.    Arch.  d'Opthal.  July,1898. 

3396.  Gayet,  On  the  temporary  folding  back  of  the  cornea  for  the  purpose 

of  operating  a  ciel  onvert  on  the  iris  and  the  capsule  of  the  lens. 

Ann.  d'Ocul.,  XVIII,  p.  346. 
3396.  Harlan,  Geo.,  On  delayed  imion  after  cataract  extraction.     Report 

of  Trans,  of  Amer.  Opth.  Soc.  1898.     Arch,  of  Opth..  Vol.  XVII. 

p.  455. 
3.398.  Heine,  L.,  Beitrage  zur  physiologic  und  pathologie  der  linse.    Graef 

Arch.,  Bd.  XLVI,  Part  HI,  p.  525. 

3399.  Hippel,  B.  v.,  Uber  das  normale  auge  des  neugeborenen.     (^raefe's 

Arch.,  Bd.  XLV,  Part  II,  p.  286. 

3400.  Hippel,  E.  v.,  Uber  anopthalmus  congenitus.     Graefe's  Arch.,  Bd. 

XLVI  I,  Part  I,  p.  227. 
.3401.  Hidaka,  Takashi,  Tokyo.    A  contribution  to  statistics  on  cataract 
operation.     Inaug.  Dissert.  Halle.    1897. 

3402.  Hirschberg.  Congenital  cataract  as  a  family  affection.   .  Centralbl. 

fur  Augen.,  Vol.  XXI,  p.  271.  Cataract  in  glass  blowers.  Berlin. 
Klin.  Woch.,  February  7,  1898.    Ann.  of  Opth.,  No.  2,  p.  247. 

3403.  Krautschneider,  A  case  of  crystal  formation  in  the  lens.    Beitrag 

zur  Augenh.,  XXVI. 

3404.  Knapp,  (1)  Recent  experiences  with  cataract  operations.     Proceed- 

ings of  the  Moscow  Internat.  Congress.  Arch.  Opth.,  Vol.  XXVII. 
No.  1,  p.  94.  (2)  On  operation  for  secondary  cataract.  Report  of 
Trans.  Amer.  Optli.  Society.  Arch,  of  Opth.,  Vol.  XXVII,  4.  p.  447. 
(3)  Recent  experiences  in  operations  for  secondary  cataract.  Arch, 
of  Opth.,  XXVII,  No.  5,  p.  467.  (4)  Remarks  on  cataract  extrac- 
tion, based  on  a  large  number  of  cases.  Opth.  Section,  12th  Inter. 
Congress  in  Moscow.  W.iest.  Opth.  (.">)  Complicated  cataracts, 
tlieir  iiiitiii-c  and  results.     .loin-n.  Auier.  .Med.  Assoc..  .Ian.  S.  1898. 


579 
1898.     3405.  Kreiwitz,  Corneal  astyginatism  after  iridectomy  ana  simple  linear 
extraction.     Inaiig.  Dissert.    St.  Petersburg,  1897. 

3406.  Lopez,  Fernando,  Expulsive  hemorrhage  after  cataract  extraction. 

Ann.  d'Opth.,  No.  1,  p.  2.     1898. 

3407.  Meyer,  O.,  Beitrag  zur  pathologie  und  pathologische  anatomle  des 

schicht  und  kapsel  staars.    Bd.  XLV,  Part  III,  p.  540. 

3408.  Muttermilch,  Notes  on  cataract  operation.     Ann.  d'Ocul.,   XVIII. 

p.  408. 
8409.  Milbury,  Report  on  70  cases  of  cataract  extraction.     Journal  of 
Amer.  Med.  Assoc,  April  17,  1897. 

3410.  Mitvalsky,  Remarks  on  subconjunctival  luxation  of  the  lens.    Arch. 

d'Opthal.,  XVII,  p.  337. 

3411.  Mittendorf,  W.  F.,  Some  of  the  earlier  symptoms  of  senile  cataract. 

Report  of  Trans.  Amer.  Opth.  Soc,  1898.  Arch,  of  Opthal.,  Vol. 
XXVII,  4,  p.  447. 

3412.  Mulder,  Anatomical  examination  of  a  case  of  lenticonus  posterior. 

Zehender's  Klin.  Monatsbl.,  XXXV,  p.  409. 

3413.  Oliver,  Clinical  history  of  a  case  of  subconjunctival  dislocation  of 

the  lens.    Opth.  Record,  June,  1897. 

3414.  Puccioni,  A  case  of  spontaneous  luxation  of  both  lenses.     Boll. 

d'Ocul.,  XVIII,  14-15,  p.  108. 

3415.  Pfluger,  Prevention  of  prolapse  of  the  iris  in  extraction  of  the  senile 

cataract.  Proceedings  of  Moscow  International  Congress.  Arch, 
of  Opthal.,  Vol.  XXVII,  Part  I,  p.  95.  Zehender's  Klin.  Monatsbl., 
XXXV,  p.  332. 

3416.  Purtscher,   Congenital  cataract  as  a  family  affection.     Centralbl. 

fur  Augenh.,  Vol.  XXI,  p.  198. 

3417.  Purtscher,  Choroidal  hemorrhage  after  extraction.     Centralbl.  fur 

Augenh.,  XXI,  p.  193. 

3418.  Rogmann,  A  new  contribution  to  the  study  of  the  congenital  anom- 

alies of  the  lens.  Colobomas  situated  in  direction  not  correspond- 
ing to  the  foetal  cleft.  General  conclusions  on  the  genesis  of  len- 
ticular colobomas.    Arch,  fur  Opth.,  XVII,  p.  427. 

3419.  Rauschenbach,   A  contribution  to   the  pathology  and   therapy  of 

traumatic  cataract.     Inaug.  Dissert.    Basle,  1897. 

3420.  Sattler,  H.,  Zuzatz  zur  Bloom'schen  Arbeit.     Uber  die  retro-cho- 

roideal  blutungen  nach  staar  extractionen.  Graefe's  Arch..  Bd. 
XLVI,  Part  I,  p.  184. 

3421.  Schweigger,  C,  Simple  extraction  downward.    Arch,  of  Opth.,  Vol. 

XXVII,  No.  3,  p.  255.    Ann.  of  Opth.,  Vol.  VII,  No.  2,  p.  240. 

3422.  Schantz,  A  family  with  juvenile  cataract.    Centralbl.  fur  Augenh.. 

Vol.  XXI,  p.  264. 

3423.  Schoen,  Cataract  following  convulsions.  Wiener  Med.  Wochenschr.. 

No.  17.    1897. 


58o 

1898.     3424.  Sattler.    On  tlie   operative   treatment  of  ectopia  lentis.   Arch,   fur 
Augenh.,  XXXV,  4,  p.  355. 
3425.  Sourdille,  Daviel's  section,  accordiu.s,  to  authoritative  texts.    Arch. 

f.  Optla.,  XA^I,  p.  657. 
3420.  Scliiotz,   Cataract  statistics.     Nord.   Mag.   f.   Lageridsk.   F'orhaudl. 
Christiana,  1897,  p.  159. 

3427.  Schumway,   E.   A.,   Summary  of  operations  for  cataract,  done  at 

New  Yorli  Eye  and  Ear  Infirmary,  October.  1895,  to  October,  1896. 
January,  1897. 

3428.  Trousseau,  Treatment  of  hemorrhage  after  extraction  of  cataract 

by  corneal  suture.    Arch.  f.  Opth.,  XVII,  2,  p.  106. 

3429.  Trocavo,  Uribe,  Delay  in  the  past  operative  formation  of  the  an- 

terior chamber.    Ann.  d'Opth.,  Vol.  I,  No.  1.   July,  1898. 

3430.  Valois,  G.,  Delay  in  cicatrization  after  cataract  operation.    Recueil 

d'Opth.,  January,  1898. 

3431.  Velhagen,  A  case  of  pseudo-neoplasm  in  the  interior  of  the  eye  after 

cataract  extraction.     Centralbl.  fur  Augenh.,  XXI,  p.  363. 

3432.  Wettendorfer,  A  contribution  of  the  aetiology  of  juvenile  total  cat- 

aract.    Wiener  Med.  Wochenschrift,  1897,  Nos.  11  and  12. 

3433.  Wilson,  F.  M.,  Senile  cataract.    Trans.  Conn.  Med.  Soc.    1895. 


INDEX, 


ACCOMMODATION— 

Abolition  of  (Traumatic  Lux- 
ation)      157 

Aphakia  in    364 

Artificial  (in  Aphakia) 400 

Beirinning  of 3(5,  97 

Diminution  of 49 

Developing  cataract  in l'^6 

Effort  at,  after  Extraction,  (its 

consequences) 364 

History  of  Subject 384 

Eelation  to  Shape  of  Lens.  .  .  36 
AETIOLOGY  OF  CATARACT.  135 

(See  also  C.  Senilis.) 
ALBUMEN— 

Increased  Amount  in  Cataract     72 

Modification  of 65 

Normal  Amount   of,   in    nor- 
mal lens 63 

Kali-A 62 

Serum-A 62 

ALBUMINOUS  SUBSTANCES— 

(In  the  Lens) 64 

Quantitative  Estimate 65 

ALBUMINURIA— 

(A  Cause  of  Senile  Cataract) . .  236 
AMBLYOPIA  ex  ANOPSIA. .  .  414 
ANOMALIES  (of  the  I^ns)— 

Cause- of 138,  148 

ANOPTHALMUS— 

Aetiology  139 

Condition  of  Lens  in 140 

APHAKIA— 

Accommodation  in 384 

Artificial  Ace 400 

Astygmatism  in 388 


Average  ^Measurements  in  Em- 

etropic  Eye 380 

Cause  of 372 

Definition,  Diagnosis 372 

Dioptric  Sytem  in 376 

Emetropic 377 

Glasses  in — 

Cylindrical 404 

Influence  of 405 

Spherical   402 

Hyperopic    •  •  •  •  376,  379 

Myopic  379 

Optical  System  in 374 

Peculiarities  408 

Pupil,  appearance  of 338 

Vision  in  Acuity  of  (Real  and 

Apparent)   397 

Acuteness  of 387 

Diminution  of,  (cause) 388 

APHAKIC  EYE— 

Appearance  of 338 

ARTIFICIAL  RIPENING  OF 

CATARACT 264,  357 

ASHES— 

Normanl  Lens 64 

ASTYGMATISM— 

After  operation,  cause  of  .348,  392 
After  partial  rupture  of  Zon- 
ula      155 

Degree  and  effect  of 389 

Influence  of  operation  on  de- 
grees      ^^"* 

Irregular,  cause  of 314 

ATHEROMA  of  the  CAROTID— 

Cause  of  Senile 236 

Choroidal  Vessels 240 


582 


INDEX— Continued. 


ATEOPINE- 

After  Extncction 332 

Danger  of  Glaucoma. 354 

During  Extraction 352,  361 

Histon-  of 116 

Physiological  action 311 

Use  of  C.  Incipiens 127 

AQUEOUS— 

Albumen  in 71 

Albumen  during  cataract  for- 
mation        72 

Chemistr}'  of 69 

Evacuation  of,  Effect  on  con- 
tour of  the  lens 36 

Effect  of  repeated  puncture  on 

chemical,  constitution  of . . .   264 
Effect  on  position  of  the  lens.   297 

Historical  review 108 

Index  of  Eefraction 70,  374 

Nutritive  fluid  of  Eye 318 

Ee-accumulation  of 336 

Sugar  in 71 

BACTEEIOLOGY— 

Importance  in  operating 362 

BUPHTHALMUS— 

Influence  on  the  Lens 168 

CAPSULA  LENTIS— 

Condition    of    (after   Extrac- 
tion)      349 

Corpuscles 45 

Construction  of 45 

Contraction  of 98 

Development  of,  (Time  of). 25,  27 

Dioptric  influence 375 

Elasticity  of 46 

Function 26,     27 

Growth 43 

Injuries  of,  by  cutting  instru- 
ments     252 

Lamellae,  (Zonular) 44 

Ledges 40 

Measurements       43 


Origin,  (experimental  investi- 
gations)         44 

Perforation,  result  of  traction 
of  cyclitic  bands 203 

Physical  properties 45 

Pores 55 

Pressure,  (Intracapsular) — 

Fall  of 98 

Limiting  formation  of 
fibres   97 

Puncture  of,  (closure) 253 

Eeaction  of — 

Capsule  after  operation ... .   309 
Contents  of  capsule  after.  .   309 

Eupture  of 251 

Et  Zonula  Zinii 251 

Stomata   94,  256 

Swelling  of 56 

CAPSULAE  CICATEICES— 

Development 44 

Foreign  Substances  enclosed.  94 

Growth 45 

Pathology 90 

CAPSULAE  FOECEPS— 

Value  of 309 

CAPSULOTOMIE.      (CYSTO- 

TOMIE)   309 

Mode  of  procedure.  .306,  307,  350 
Dangers  of 309 

CATAEACTA.     CATAEACT— 

Origin  of  word 109 

(N.  B. — For  all  general  con- 
siderations see,  Cataracta 
Senilis — Senile  Cataract.) 

C.  ACCEETA 114,  198 

(See  C.  Complicata.) 

C.  ADVEESA 115 

C.  ACQUISITA 113 

C.  AEBOEESENCE 116 

C.  AEIDO  SILIQUATA 114 

Aetiology,  Genesis 213,  214 


583 

INDEX— Continued. 

C  x\XIALI3-                               "'"  C.  CAPSULARIS  CUM  BUR-  ""'' 

Definition  113  SA     ICHOREM     CONTI- 

C.  AXIALIS  ANTERIOR—  NENTE    •••••••••••  —  •   ^'^ 

(See  C.  Pyramidalis.)  C.   CAPSULARIS  LENTICU- 

Definition  174  LARIS 113 

C.  BEUNESEn'ce:  ■.;;;'.'.;;■.'.  84?  C.  C APSULAEIS  NATAUS  . .  115 

(See  C.  Nigra.)  C.    CAPSULARIS   PUNC- 

•  TATA  174 

C.  CALCAREA—  

Anatomical  description 201  C.  CENTRALIS— 

CUnical  History     166        Definition   113,  174 

Definition   113        Description,  Genesis 175,  185 

Perception  of  Light 132        Pathology 194 

C  C  \PSUI  ARIS-  ^^'^  ^-  2°^^^^^^^-) 

l.LArbUi.AKife  C.  CENTRALIS  ANTERIOR'..  113 

Chemical  constitution....  92  ^     CENTRALIS     CAPSU- 

Chmcal  descnption .      .  .  249,  258  ^^^^^  POSTERIOR 113 

Contraction    o  ,    leading    to  ^      CENTRALIS    LENTICU- 

spontaneous  luxation 15d  t  at?TS  113 

^®^"^'*^°^  ;•••••   ^^^  C.  CENTRALIS  POSTERIOR.  113 

Foreign  substances  enclosed — 

(Clacoxeous  depoeits) 94  C.  CHOROIDEALIS- 

Cholerterine) -        Climeal  m.tory   304,  206 

Generis  of 246.  258  DiffcT«itiation    from    C.  Po- 

Hyaline  Thickening .339  ^^^\^-  ??»"») 1** 

Localized  growth,  can»  of. . .   101        Nntnt.ve  Di^urbances 207 

General  consideration 89  (^^^  C.  Punctata.) 

Genesis  -  Historical       Re-  C.  COMPLICATA- 

Tiew 89,  246        Aetiology    136 

,     Primary  development 249  Anatomical  Examinations.  ...   199 

Petrifaction  103  Clinical  History   and   Sequel- 
Presence  in  Senile  Cataract. . .   233            l^e 

C.  CAPSULARIS  ANTERIOR  Definition 114,  136.  198,  340 

CENTRALIS 113        Operative  interference 204 

(See  C.  Polaris  Anterior.  Con-  C.  COMPLETA 115 

genitaetAcquisita.)  C.    COMPOSITA    CRYSTAL- 

C.  CAPSULARIS  ANTERIOR  LINAE 115 

SPURIA—  (See  C.  Capsularis.) 

Aetiology 144  C.  CONGENIT A- 

Definition  112        Definition 113 

C.  CAPSULARIS  ARIDA  SII^  C.  CONGENITA  NUCLEARIS 

IQUATA    115  DURA 215 


584 


INDEX— Continued. 


Description,  Operations  Path- 
ogenesis    216 

C.     CONGENITA     TOTALIS 
OCULI  UNTEIUSQUE— 

Aetiology   213 

Anatomical  Examination .  207,  211 

Genesis   209,  213 

Time  of  occurrence 213 

Varieties 207 

C.  CONSECUTIVA,  (Constitu- 
tional Cataract) —  . 

Changes  incipient 59 

Definition 99,  113,  205 

Pathogenesis 99 

C.     CONSECUTIVA     P  A  E  - 
TIALIS.    (See  C.  Axialis.) 
C.  COETICALIS— 

Anterior,  Posterior 113 

C.  CYSTICA— 

Definition   115,  214 

C.  DIABETICA— 

Aetiology 226,  240 

Anatomical  Examinations. . .  217 

Chemistry  of 67,  223,  227 

Clinical  description.. 219,  220,  225 

Development,  Period  of 219 

Diabetic  Coma 230 

Experimental  production  of.  .  237 

Frequency  of 218 

General  condition  of  patient..  219 

Genesis 82,  229 

General  consideration. .  .216,  225 

Pathology  of 80,  220,  222 

Pathogenesis  .  .  .99,  216,  222,  225 

Pigmentation    223 

Prognosis  of  operations 229 

Eelation    of    cataract   forma- 
tion to  quantity  of  sugar  in 

the  urine     223 

Sex  affected 219 

Varieties 319 


C.  DURA— 

Definition  113 

C.  EIvASTICA— 

Cause  of 154 

Definition,  Description 214 

C.  EX  CONTUSIONE 250 

C.  FLUID A- 

Definition   113 

Perception  of  light  in 132 

C.  FUSIFOEMIS.  (Spindle  Cat- 
aract)— 
Clinical  description  and  his- 
tory     180 

Genesis   176,  181 

C.  GLAUCOMATOSA— 

Definition   114 

C.  GYPSEA— 

Definition   113,  202 

Perception  of  Light 132 

C.  HEMOEEHAGICA 247 

C.  HYPEEMATUEA— 

Clinical  Data 233 

Definition   114 

Sequellae  342 

C.  HYPEEMATUEA  FLUIDA  242 
(See  C.  Morgagniana.) 

C.  HYPEEMATUEA  EEDUC- 
TA— 
Aetiology    and    Clinical    De- 
scription      242 

C.  ICHOEEM  TENENS— 

Definition  113 

C.  INCIPIENS— 

Definition     11  x,  115,  233 

Pathology 80 

C.  INANITION 207 

C.  JUVENUM— 

Calcareous  Deposits  in 82 

Changes .     59 

Definition  113 

Genesis,  Pathology 80 


INDEX— 

C.  LACTEA— 

Definition   113,  114 

Description    and     difl'erential 

diagnosis    202,  24o 

C.  LAPIDA- 

Dofinition   113 

C.  LA:\IELLAE.     (See  C.  Zon- 
ula ris.) 
C.  LEXTICUEAT^TS— 

Definition   112 

History    116 

C.    LENTICULAIJIS    COinT- 

CALIS 112 

C.  LENTICULARIS  NUCLE. 

AT?IS 112 

C.LEXTICULAEIS  TOTALIS  113 
C.  MATURA— 

Clinical  Data 233 

Definition 114.  233 

Pathology   79 

C.  MATURESENCE— 

.  Definition   114,  233 

C.  MEMBRArACEA— 

Definition  114 

Diagnosis  368 

Genesis    213,  258 

Pathology 102 

Treatment 367 

C.     MEMBRANACEA     CON- 
GENITA— 

Aetiology 214 

C.    MEMBRANACEA    CON- 
GENITA ACCRETA— 
Description,    Pathology,   and 

Aetiology 143 

C.  MOLLIS— 

Definition  113 

C.    MOLLIS    EX    CHOROID- 

ITIDE  204 

C.  MOLLIS  JUVENUM.    (See 
C.  Diabetica.) 


585 
CONTINI'ED. 

C.  MOWGAGNIANA— 

Anatomical  Examination.  . .  .   243 

Cause  of 1 1  r,,  245,  246 

Clinical  description 242 

DefiniHon 113,  115,  245 

Genesis 246 

History    243 

Nucleus 245 

Pathology  80,     89 

Perception  of  Light 132 

C.  MIXTA— 

Definition   113.  115 

C.  NATALIS.    (Natans.)— 

Cause   : 153 

Description 214 

Definition 114,  115 

C.  NIGRA— 

Anatomical  P]xamination ....   248 

Chemistry  of 69 

Clinical   description 248 

Definition   114,  249 

Genesis   247 

Historical 115,  247 

Pathology   79,  247 

Spectroscopic  Analysis 69 

Varieties  67,     79 

C.  NONDUj\I  MATURA— 

Definition  114,  233 

C.  NUCLEARIS— 

Anatomical  Basis 80,  185 

Differentiation  from  C.  Zon- 
ularis    182 

C.  NUCLEARIS  CONGENITA 
DURA— 
Description  and  Genesis 215 

C.  OSSEA— 

Definition  113,  203 

C.  PARTIALIS.     (See  C.  Ax- 
ialis.) 

Definition    113,  174 

Effect  on  Vision 124 

Varieties   196 


586 


INDEX— Continued. 


PAGE 

C.  PIGMENTAIEE 223 

C.      POLARIS      ANTERIOR 
(Pyramidal)  s) — 

Cause  of 153 

Definition  and  description. . .   176 

Pathogenesis   100,  176 

Varieties  and  identity lOl 

C.  POLARIS  ANTERIOR  AC- 

CRETA  179 

C.  POLARIS  ANTERIOR  AC- 
QUISITA— 

G-enesis   178 

C.    POLARIS   ANTERIOR 
CONGENITA— 

Description  and  Genesis 177 

C.  POLARIS  POSTERIOR  in 
RETINITIS     PIGMENT- 
OSA— 
Anatomy,  Description,  Gene- 
sis and  Diagnosis 205,  206 

Nutrition  of 207 

C.      POLARIS     POSTERIOR 
SPURIA— 

Description  and  Genesis 144 

C.      POLARIS     POSTERIOR 
VERA— 
Diagnosis  and  Genesis.  .  .180,  185 
C.  PROGRESSIVA— 

Definition  113 

C.  PUNCTATA— 

Cause  of 39 

Description  and  Pathogenesis.  196 

Varieties  197 

C.  PUTRIDA— 

Definition  113 

C.  STATIONAIRE— 
Definition  113 

C.  SECUNDARIA,  (Acute  In- 
flammatory)          99 

C.  SECUNDARIA,  (Simplex)— 
Cause  of 310.  335,  364 


Definition 114,  339,  257 

Genesis 98,  339 

Origin   99 

Presence  of  Vesicles 88 

Varieties  99 

0.  SECUNDARIA   ACCRETA 

COMPLICATA— 

Cause  of 340 

Course,     Definition,     Clinical 

Histor}'   258 

Interference      with      Vision, 

cause  of 258 

Operation    351 

Pathology   352 

Sequellae   352 

C.  SENILIS.   (Senile  Grey  C.)— 

Aetiology 59,  76,  81,  96, 

135,  234,  240,  and 241 

Albumen,  Increase 72 

Cataract,  (Origin  of  Word) .  .   109 

Changes  Incipient 77 

Classification 113 

Clearing  up  of 261 

Clinical  Data 232 

Colors,  perception  of 132 

Definition.  .  .17,  59,  104,  113,  232 

Diagnostic  features 116 

Facial  Appearance  of  Patient. . .   125 

Genesis 78,  96,  234 

His/tor}^  of .104,  116 

Influence  of  Refractive  Con- 
ditions      132 

Light,  perception  of 131 

Luxation  Spontaneous 153 

Measurements  of 304 

Microscopical  changes. 80,  97,  232 
Myopia  during    cataract  for- 
mation    61,  126 

Opacities,  frequency  of 205 

Opacities,  increased  by  punc- 
ture of  Anterior  Chamber..  264 
Pathology 75,  76,  79,  332 


INDEX — Continued. 


587 


Pathogenesis 99 

Predisposition     to      Heredit- 
ary     835,  341 

Prognosis   to   second   affected 

eye 347 

Refractive  Conditions. .  .126,  133 

Resorption  Spontaneous 262 

Ripeness  of '^^,  833 

Symptoms,  Subjective 123 

Varieties   113 

Vision,  interference  witli.125,  129 

Volume,  reduction  of "9 

C.  SENILIS  PRAEMATURA— 

Aetiology  830 

C.  SENILIS    PRAEMATURA 
NUCLEARIS— 
(See  also  C.  Nuclearis). 
Clinical  History.  Course,  Gen- 
esis, Prognosis 231 

C.  SENILIS    PRAEMATURA 

PUNCTATA  

(See  C.  Punctata.) 
C.  SPURIA— 

Definition  .112, 

C.  SPURIA  ANTERIOR— 

Cause  of 

C.  SPURIA  POSTERIOR— 

Cause  of 

C.  STATIONAIRE— 

Definition   113 

C.  STELLATA 116,  198 

C.    of    SUDDEN    DEVELOP- 
MENT     216 

C.  TOTALIS— 

Definition   113 

Refraction 185 

Vision   125 

C.  TRABECULARIS 115 

C.  TRAUMATICA— 

Aetiology 81,  137,  250 

Clinical  Description 250,  254 


196 


115 


144 


144 


Color  of 254 

Complications  252 

Definition   115,  250 

Pathology  81.  255 

Prognoas 298 

Treatment   367,  365 

C.  TREMULA.  (Vel  Natalitis)— 

Aetiology 153,  214 

Definition   115 

C.  VERA— 

Deiinition 112,  115 

C.  ZONULARIS,  (Lamellar  C.)— 

Aetiology  189 

Anatomical  Examination 184 

Clinical  Histon'  and  Descrip- 
tion      182 

Differentiation  from — 

Nuclear  Cataract 182 

Senile  Cataract 183 

Lamellae,  number  of  involved  183 

Nystagmus   185 

Occurrence  in  both  eyes. .  183,  189 

Pathogenesis   38,  192 

Transition  to  Senile  C 183,  188 

Time  of  Development 195 

Vision,  degree  of 125,  188 

Volume 183 

CATARACTOUS  REMAINS— 

Effect  on  Vision 334 

Element  of  Danger 335 

Sequelae 336 

CENTRAL  PLANES 39 

CHOLESTERINE— 
Amount  in — 

Normal  Lens 62,     63 

Cataractous  I^ens 66,  123 

All  ages  of  life 66 

CHOROIDITIS  SEROSA— 

Effect  on  Position  of  the  Lens  168 
CILIARY  BODY— 

Contraction  after  Extraction.    364 
Detachment  of 353 


588 


INDEX— Continued. 


Function    

36 

CYCLOPS— 

Injury  of 

155 

Description,  Aetiology.  .  .142, 

143 

Irritation   

352 

CYSTOID  CICATRIZATION. 

331 

Tension  on 

352 

DAVIEL,  JACQUES— 

Violent    traction   on,    during 

Sketch  of  his  life.— Value  of 

Extraction                       367 

368 

his  work 272, 

280 

COETEX   

49 

DIAPHRAGM— 

COCAINE— 

Use  in  diagnosis  of 

128 

Effect  of  its  use  during  Ex- 

DIPLOPIA— 

traction  317, 

324 

After  Cataract  Extraction .  .  . 

413 

Histon^  of 

116 

Monocular  Luxatio  Lentis.  .  . 

153 

COLOBOMA  LENTIS— 

Mono.cular  Ectopia  Lentis.  .  . 

148 

Genesis  and  Description 

146 

DISCHARGE  of  natient  from 

COLOBOMA  TOTALI  OCULI- 

_ 

physician's  care 

363 

Causation  of 138, 

140 

DISLOCATIO   LENTIS.    (See 

COMA  DIABETIC 

230 

Luxatio.) 

CONCUSSION     OF     EYE- 

DISCISSION. (See  Operations.) 

BALL— 

DRUSEN— 

Effect     on     cataract     forma- 

Genesis  83,  84,  101, 

339 

tion    160, 

251 

ECTOPIA  LENTIS— 

CONJUNCTIVA  BULBI— 

Genesis 

Involvement  in  operation .... 

312 

General    Consideration,    His^ 

CORNEA— 

tory,  Ohjective,  Symptoms, 

(See  Operations.) 

Symptomatology 148, 

150 

Ulceration  Secondary  to  Glau- 

Free movement  of  Lens 

162 

coma  after  Luxation 

165 

ELECTRICAL  TREATMENT 

Varying  thickness  of 

326 

FOR  CATARACT 

260 

CORNEAL  CURVATURE— 

ENTOPTIC  OBJECTS...  127, 

408 

After  Extraction  Astygmatism 

In  Luxatio  Lentis 

152 

IiTCgular     

348 
391 

ENZYM   

95 

Astygmatism  Regular 

EPITHELIUM  of  ANTERIOR 

Radius  of  Curvature 375, 

377 

CAPSULE— 

CORNEAL  MICROSCOPE. . .. 

122 

Changes  due  to  age.  . 

51 

CRYSTALLOCONUS.      (See 

Foetal  Origin 

19 

Lenticonus.) 

Foetal  Development 21 , 

22 

CRYSTALLINE  PEARL.  (See 

Formative  cells 

86 

also  Sommering's  C.  P.) 

Function  of 

249 

Occurrence  after  Reclination. 

290 

Genesis  of  new  cellular  for- 

Pathology of 88, 

98 

mations  97, 

98 

CYCLITIS— 

Histology  of 

52 

After  Luxation 158, 

159 

Hyperplasia 59,  85,  96, 

310 

After  Operation 

353 

Karyokinetic  changes 

42 

INDEX— Continued. 


589 


Patlio«i-enesis  of  restricted  re- 
production      103 

Pathological  changes — 

Atrophic  nev\^  cellular  for- 
mations   84,  101 

Degenerative   83 

Hyperpalsia 100 

Perverse  98 

Progressive  96,  100 

Eegenerative 84,  161 

Retrogressive 103 

Reaction,    after   opening    the 
Capsule 309 

Sizeof 41,  53,     85 

EPITHELIUM    of    the    POS- 
TERIOR CAPSULE— 

Genesis 85,     86 

Pathology 85 

Pseudo  Epithelium 87 

ERYTHROPSIA  408 

ESERINE— 

Use  of 300,  302,  361 

Value  of 301 

EXTRACTION.      (See    opera- 
tions.) 
FAT  in  Senile  Lenses — 

Ox  Lens 63,     66 

FOCAL  ILLUMINATION. ...   117 
FIBRES  LENS— 

Abnormalities   38 

Arrangement — 

Foetal 20,     23 

Extra-uterine   35 

Attachment,  mode  of.  .33,  36,     39 
Development  of — 

Foetal 21 

Second  period 31 

Third  period 33 

Distal 30 

Focal  illumination 11''' 

Formation  of  new  fibres 41 

Formation,   limitation    of   by 
Intracapsular  pressure 97 


Grow  til — 

Pktra-uterino    37,  38 

Foetal 22,  33 

Irregularities  of 38 

Length  of  extra-uterine. .  .25, 

35,  36,  37,  and 42 

Length  of  foetal 33 

Morphological  changes 49 

Nuclei  of.    (See  Nuclei.) 

Origin,  line  of 35 

Physical  changes 50 

Proximal 30 

Proximal,  transition  of 31 

Refraction,     index     of,      in- 
crease    50,  60 

Retrogressive  changes 103 

Serrated  .  .  .  .' 49 

Vascuoles 83 

Vitreous,  action  of ,  on 354 

FIELD  OF  VISION— 

Contraction  of,  in  Aphakia...  405 

Defects 134 

Importance     of    determining 

oefore  operation 134 

FOCAL  ILLUMINATION....  117 

Edge  of  Lens 119 

FORMATIVE  CELLS 43,  86 

GERONTOXON  LENTIS.  .77,  361 

GLASSES,  CATARACT— 

Centering  exact 407 

Cylindrical  correction 404 

Influence  of 405 

Selection  of  proper 377 

Spherical  correction 403 

Time  to  begin  use  of 353,  364 

GLOBULINE 63 

GLAUCOMA— 

Idiopathic 356 

Influence  on  Position  of  the 

Lens   168 

Producing  opacities  of  Lens .  .   192 
Secondary  to  Atropine.  Use  of  354 


59° 


INDEX— Continued. 


Cystoid  Cicatrization 328,  354 

Depression    288,  294 

Discission   297,  368 

Extraction  310,  353 

Healing  of  Wound 165 

Injuries  of  the  Lens 366,  368 

Luxation  of  Lens  into  ante- 
rior chamber.  160,  161,  163,  165 
Spontaneous  sinking  of  a  Cat- 

aractous  Lens 371 

Symptom  of,  and  prevention 

of 337 

Subluxation 158,  159 

GEAEFE,  VON— 

Historical  notes 276 

Estimate  of  his  work 279,  280 

HAEMATIN  in  the  Lens 122 

HEAT— 

Influence  of,  on  the  Lens.  ...     51 

HEMOERHAGE  INTRAOCU- 
LAR— 

Choroidal,  avoidance  of 165 

Concussion  et  Contusione. .  .  .  251 

Cause  of 311 

During  Extraction 315 

During  Extraction    of   freely 

movable  lenses 166 

During  healing  process 345 

Retinal  311 

Seleronyxis 285 

Iris  from 306,  317 

Intra-Choroidal   315 

HISTOLYSE  96,  256 

HYALINE  DEPOSITS 40 

HYALINE  EXCRESCENCE . .  83 

Genesis  of 84 

HYALOID  ARTERY— 

Influence  on  Cataracta  Mem- 
branacea     Congenita     Ac- 

creta  143 

Malformations   of   Lens   Sys- 
tem   ".  .  138 


HYDROPTHALMUS  338 

HYDROPSICAL  CELLS 88 

(See  Wedl's  Cells.) 

Genesis  of 103 

HYPERMETROPIA— 

Acquired 17 

INTRACAPSULAR    P  R  E  S  - 
SURE— 

Limitations  of 97 

INDENTED    LENS.       (See 

Notched  Lens.) 
INJURIES  of  Lens,  Recent— 
(See  also  C.  Traumatica.) 

Treatment 365 

INTERFIBRILAR  SPACES..     39 
IRIS— 

Differentiation    of    Cicatriza- 
tion of  stump 331 

Hemorrhage  from 306,  317 

Hyperaemia  of 333 

Involvement   in    Simple    Ex- 
traction     312 

Prolapse  of,  cause  an  sequel- 

lae 301,  332 

Shadow  in  Senile  Cataract. ...   234 

Tension,  effect  of,  on 330,  331 

IRITIS— 

Plastic,  (after  operation) 333 

Relapsing    334 

Suppurative 343 

Secondary  to  Lens  in  the  An- 
terior Chamber 163 

Traumatic,  (Simple) 332 

IRIS  SHADOW 233 

IRIDECTOMIE— 

Advantages  vs.  disadvantages 

of 275,279,300,  301,-312 

Aesthetic  objections  to 302 

History  of,  (in  Extraction) . . .   330 

Indications  for 300 

Secondary   Cataract,    position 

of  in . ". 368 

Size  of 302,  306 


INDEX— Continued. 


59' 


IRIDO-CYCLITIS— 

Eelapsing  form 334 

lEIDONESIS— 

Luxation  Traumatic 158 

Value  in  Diagnosis  of  Apha- 
kia     372 

KERATINE 65 

KERATITIS— 

(Rand  K.)  Striated 322 

LECITHIN— 

Amount  in  normal  Lens.  .62, 

63,  and 64 

LEDGES 40 

LENS— 

Adherence  to  Cornea 164 

Absence  of,  Total 140,  141 

Analysis  of  Chemical 62 

Analysis  of  Quantitative 64 

Calcareous  Deposits  in 82 

Calcification  of 201,  296 

Changes — 

Physical   58 

Progressive 57 

Chemical   difference   between 
inner    and    outer    portion 

of 50,  51 

Chemistry  of 61 

Color,  loss  of 58 

,  Cortex  of 49 

Development  of — 

First  Period 19 

Second  Period 20 

Completed   21 

Third  Period 22 

Completed 24 

Relation   between   develop- 
ment      of       Eye       and 

Lens 138,  141 

Dimensions,   Equatorial   Sag- 
ittal  31,  33,  34 

Dryness  of 58 


Displacement  of — 

(See  Ectopia  Lentis) 

(See  Luxation  Lentis) 

Focal  illumination  of 

Foreign  Bodies  in  the — 

Clinical  History  and  Diag- 
nosis of  Foreign  Bodies 
which  penetrate.  . .  .253, 

Chemical  tests  for 

Reaction  to 

Sequelae  of 

Spontaneous    clearing    up, 

after  

Form  of — 

Attained,  Time  of 22, 

Change  at  Birth 

Effect  of  Aqueous 

Effect  on  Accommodation. . 
Growth — 

Developmental   

Intra  and  Extra-uterine .  30, 

Rapidity  of  Intra  and  Ex- 
tra-uterine    34, 

Hardness 

Index  of  Refraction 

Injuries  of 250, 

Peripher}-   

Subsequent  Clearing  up  of . 

Treatment  of 

Lamellae 

Lymph  spaces 

Luxation    of.      (See    Luxatio 

Lentis.) 

Malformations  of 

Morphological  changes 

Nucleus  of.    (See  Nucleus.) 
Nutrition- 
Effect  of  repeated  puncture 
of  Anterior  Chamber. 71, 

Interference  with 

Mode  of 

Theories,  Experiments.  .53, 
58,  and 


148 
150 
117 


254 
257 
257 
254 

254 

30 
36 
36 
36 

23 
31 

38 

59 

59 

252 

252 

254 

365 

38 

57 


137 
49 


264 
58 
53 

71 


592 


INDEX— Continued. 


Opthalmoscopic  P]xaniination.  118 

Oscillation  of 151 

Ossification  of 202 

Pathology  of 75 

Petrifaction  of 103 

Ph3'siology  of 53 

Pliysical  changes 58 

Position  of,  in  fishes 35 

Pus  in  the 94,  95 

Refractive  medium 3G 

Relation  of  Diameter    of  the 
Lens  to  the  Diameter  of  the 

Eye-ball   33 

Retrogression,  Physiological..  48 
Role  of,  in  formation  of  Eye- 
ball   138,  141 

Sclerosis  of 79 

Specific  Gravity 31 

Structure  of 23 

Temperature  of 63 

Two  lenses  in  one  eye 142 

Tumors  of 102 

Vascular  Capsule  of 138 

Volume  of 31,  58,  97 

Weight  and  Volume  of  Cata- 

ractous  Lenses 58,  64,  97 

'  Of  Foetal  Lenses 31,  58 

LENTO  ALBUMEN— 

Globuline 62 

LENTICONUS— 

Anterior 169 

Posterior 170 

Diagnosis,    History,    Clinical 

Description 169 

Aetiology 173 

LENS  WHORL 25 

TJOHT— 

Distance  at  which  recognized 

in  Cataract 132 

Influence  of 35 

Perception  of  Qualitative.  .  , .  133 

Quantitative  130,  132 

Prismatic  Deflection 129 

Projection 133 


LIGHT  SENSE— 

Determination  of  in  Cataract .    131 

LINSENWIRBEL 25 

(See  Lens  Whorl.) 

LIQUOR  MORGAGNI 115 

LITERATURE 415 

LUXATIO  LENTIS— 

Acquired;  AnomaHes  of  posi- 
tion     150 

Freely  movable  lenses 162,  165 

Spontaneous — 

Cause  of 74,  152,  166,  249 

DescriptionyClinical  History, 
Symptoms.150, 152, 154,'  266 

In  Cataractous  Lens 266 

Therapy  370 

Subluxatio — 

Aetiology 160 

Prognosis,    Symptoms   and 

Treatment  158 

Dangers   163 

Totalis— 

Adherent  to  Cornea 164 

Causation,  Symptoms,  Di- 
agnosis, Various  Posi- 
tions   166,  167 

Treatment   160,  167 

Into  Vitreous 161 

Into  Anterior  Chamber...  .    163 
Traumatica — 

Causes,  Results..  .154,  157,  166 

Secondary 167 

MATURATION    OF     CATA- 
RACT   264,  357 

MEMBRANC   CAPSULO  PU- 
PILLARIS— 

Origin  of 28 

MENTAL  DERANGEMENTS 

after  Operation 363 

MICROPTHALMUS— 

Aetiology 139,  140,  141 

Condition  of  Lens  in 140 


INDEX— Continued. 


593 


MORGAGNI'S  GLOBULES— 
39,  40,  and 80 

MOTHER  CELLS 42 

MOUSCHES  VOLAXTES.  ...   128 

NAPTHALIN       E  X  P  E  R  I  - 

MENTS 57 

NOTCHED  LENS 169 

NUCLEI  OF  FIBRES— 

Death  of 41,     50 

Diminution  of 51 

Increase  of 41 

Position  of  Extra-uterine .  .  25,  37 
Position  of  Intra-uterine.  ...  20 
Size  of 41,     85 

NUCLEUS— 

Chemical  Constitution .  50,  66,  334 


Color 


Embryonal .  . 
Influence  on 

tion   

Role    in      Cataract 

tion   


49 


133 


232 


.22,  30, 
Percep- 
..  .132. 
Forma- 

80, 

Softening  in  Cataract  Forma- 
tion        82 

Weight  and  Volume 245 

NUCLEAR  CURVE 25 

NUCLEAR  ZONE 25,  37,  51 

NYSTAGMUS 125,  129,  175 

OPEEATIONS. 
DISLOCATIO,        (Depression, 
Reclination) — 
Anatomical     conditions     pro- 
duced by 285 

Anatomical     examination     of 

operated  eye 288 

Capsular  changes 288 

Resorption  of 292 

Zonular  connections 289 

Conditions  affecting  results  of 

operation 286 

Definition   265 

Historical  review  of  the  opera- 
tion   266,  274 


Per  K eratonyxis — 

Derivation  of  word 

Definition   

Effect  of 

History  and  legends 268, 

Lens — 

Calcification  of 

Enclosure  in  new  C.  T..  ..293, 

Fate  of 

Path  which  Lens  takes 

Position  of 290, 

Resorption  of 

Secondary  mounting  up  of .  .  . 

285, 

Volume  of 

Vitreous — 

Reaction  to 

Fuidity  of 

Effect  on  Lens 

Per  Scleronyxis — 

Definition   

Structures  involved 

Value  of  the  operation 

Scleronyxis  Cum  Discissio — 

Evil  effects  of 

Results,  conditions  bearing  on 

final  results 

Complications 

Incomplete   

Secondary  mounting  up  of 

the  Lens 288, 

A'arious  Methods 265. 

DISCISSIO,  CATARACTAE— 
(Discission.) 

Definition   

History  of 

Instruments  used 

Indications  for 215. 

Patholocfical    processes   subse- 
quent to  operation 

Prognosis,  Treatment 

Results  of  Discission 

Spastic  contraction  of  pupil .  . 
Sequelae    


281 
26(i 

284 
282 


296 
294 
290 
293 
294 
292 

294 
291 

293 
294 
286 

266 

284 
268 

285 

287 
287 
287 

294 

267 


280 
269 
296 
299 

299 
298 
297 
298 

298 


594 


INDEX — Continued. 


Discissio  C.  Cnm  Keratonyxis- 
History  of 


•2  8 -3 


EXTRACTION— 

Definition  270 

Length  of  time  of  operation .  .   307 

Steps  of  operation 304 

Cystotomie — 

Mode  of  procedure.  .306,  307,  350 
Globe — Condition  of.  After  Ex- 
traction— 
Anterior  Chamber,  introduc- 
tion of  air  or  blood ....  313, 

318,  and 326 

Cornea,   creasing   of;  funnel- 
shaped  depression 312 

Conjunctiva    Bulbi,    involve- 
ment of 312 

Contents  of;  change  in  rela- 
tive portion 310 

Effect  of  constant  fixation  of.   312 
Elasticity  of  Coats  of  Eye-ball.  311 

Iris,  involvement  of 312 

Pressure  on,  Effect  of 311,  313 

Vitreous,  detachment  of 311 

Volume 310 

Healing      Process.  —  Abnormal 
Conditions  Developed — 
Anterior    Chamber,     restora- 
tion of 336 

Depth  of 337 

Cataractous  remains — 

Effect  of 334 

Element  of  danger  of 335 

Sequelae  of 335 

Corneal  Phthisis 341 

Cystoid  Cicatrization,   Causa- 
tion and  Clinical  History  of. 

Iris  in  Wound 327 

Capsule  in  the  wound 327 

G-laucoma 337 

Iritis  331 

Adhesive 332 


Hyperaemia  of 332 

Plastic 333 

Relapsing   334 

Irido  Cyclitis 331,  334 

Stump  of  Iris  in  the  wound. .   331 
Sympathetic  Opthalmia.  .155,  315 

Sympathetic  Irritation 352 

Wound — 

Late  closure,  cause  of 337 

Permanent  closure 302,  336 

Time  of  healing 336,  364 

Incomplete  Results 338 

Cataracta  Secundaria,  forma- 
tion of 338,  339 

Cataracta  Complicata,  forma- 
tion of 340 

Cornea — 
Infection,  Clinical  History 

and  Treatment 341 

Phthisis;    Clinical    History 

and  Treatment 341 

Cyclitis;  Clinical  Histor}^  and 

Treatment  343,  353 

Hemori'hages;  Causation  and 

Clinical  History 345 

Iritis  Suppurative 343 

Panopthalmitis 342 

Phthisis  Bulbi 344 

Tension    of    Cicatrized    Iris, 

Capsule  in  the  Wound ....   349 
Vitreous,  infection  of,  and  se- 
quelae      344 

JDetachment  of 353 

Incision — 

Corneal  Flap,(Daviel  Incision) — 
Character  and  form  of  the 

wound 273,  274,  299,  303 

Description  of    and    varie- 
ties  273,  277,  299 

History  of 270 

Incision,  size  and  rationale 
of 303 


INDEX — Continued. 


595 


InstrumeiTts  upcd 274 

Objections  to 299 

Position  sjid  Measuromonts.  347 

Peripheric  Flap 279 

Corneal     Flap.    (Sfrlhrnr/     de 

Weclcer)   .300 

Definition    and    description 

of 279.  300 

Tendency  of  wound  to  <::ap.  348 

Value  of  operation? 301 

Varieties 270 

Scleral  Flap — 

Character  of 300 

Posterior  scleral 270 

Jarohson  Flap — 

Character  of 300 

Linear — 

Applicahility  of 300 

Description  of 308 

Dangers  of 308 

Historical  Importance 309 

Linear,  Simple.  (Van  Graefe) — 

Advantages  of 303 

Character  of 278,  299 

Graefe  Knife 300 

Indications  for 299 

Size  and  rationale  of... 277.  303 

Linear  Peripherir.  (Von  Graefe) — 

Advantasres  of 275,  328 

Character  of 300 

Dangers  of 279 

HistOTv  of 275,  277 

Incision,  principle  of 278 

Position    and      measure- 
ments     347 

Tendency  to  gap 348 

Losses,  percentage  of 278 

Infection 283 

Iridectomie — 

Aesthetic  objection  to 302 

Advantages   versus   disadvan- 
tages. .  .275,  279,  300,  302.  312 


Preparatory — 

Its  advantage  and  histor\'.  . 

275,  277 

History  of 330 

Reasons  for  broad  Coloboma  330 

Size  of 306 

Irrigation — 

y\nterior  chamber  and  intra- 
capsular injection;  histor- 
ical review  and  method  of 

procedure    318 

^latu  ration — 

Indications  for 357 

Also     in     Cataracta     Senilis 

Praematura 232 

Operation — 

General  Statement 18 

After-treatment    307,  3fil 

Air  in  the  anterior  chamber.  .    318 
Capsule — 

Eeaction  of 310 

Incarceration 314 

Cataractous  Remains,  reten- 
tion of 314 

Hemon-hages.     restricted     to 

anterior  chamber 317 

Intraocular 315 

Incision,  too  large  or  small .  .  .    313 

Infection 313 

Iris,  Prolaj)S('  and  Cicatriza- 
tion        314 

Personal  Equation  of  Op- 
erator      346 

Of  Patient 347 

Pain,  significance  of 362 

Purpose  of 265 

Preparations  for 204,  360 

Reaction   307.  362 

Steps  of... 304 

Sterilization     of     instrument 

and  Evewater 304,  318, 

319,  and 331 


596 


INDEX— Continued. 


Success,  conditions  for... 304, 

309,  34G,  and 

Time  for 307,  357, 

Vitreous-Prolapse  

Procedures  and  Changes  during 
and.  subsequent  to  cataract  ex- 
traction   

\Vound,  (Corneal) — 

Cicatrix,  formation  of 

Cloudiness  after  extraction .  .  . 

Depression  and  cause  of 

Epithelium,  erosions  of.  .313, 
Irregular  Healing — 

Irritation  due  to  pigmenta- 
tion of  cicatrix 

Cicatrization  of  Iris  in  the 

wound   

Sequelae  of 

Keratitis,  various  forms.  .322, 

Late  closure,  cause  of 

Observations  of  the  regular 
healing  of  Cornea;  com- 
plicated character  of . . . . 

a.  Puncture 

b.  Linear 

c.  Flap 

Permanent  closure 

Eemoval  of  first  dressing 

Sclero-Corneal 

Time  of  healing  of  wound .  .  . 

336, 

PAGENSTECHEE'S   OPEEAl 

TION,  (in  the  Capsule)... 

73,  276, 

Genetic  Basis  for 

PiECLINATION— 

Indications   for   in    Cataracta 
Membranacea  (upward)..  .  . 
(See  Dislocatio.) 

SUCTION 

OPERATIONS,         (SECOND- 

APY)  

TndicMiJons   ;mo 


361 
414 
314 


283 

321 
324 
325 
323 


348 

349 
352 
323 
337 


320 
320 
320 
321 
336 
320 
322 

364 


310 

257 


214 

282 

365 
365 


O]iorations — 

Cataracta  Secundaria 367 

Iridectomie 368 

Agnew;  Weber;  Do  Weeker; 
Mooren;  Kruger;  Bowman.   369 

Noyes   370 

Treatment — 

Pecent  injuries 365 

True  Traumatic  Cataract.  .    367 

OPTHALMOSCOPE 77 

Diagnostic  value 118 

Histor}^  of 116 

Refracting  Opthalmoscope.  .  .    119 
Use  of  in — 

Aphakia 412 

Diagnosing  Cataract 77 

Diagnosing  opacities  in  me- 
dia       120 

OPTIC  VESICLE— 

Primary  cause  of  formation.  141 
OP  lUTAL  CYSTS— 

Aetiology  139 

Description 140 

OSSIFICATION  OF  LENS. .  .   202 
PAIN— 

Significance  of,  in  healing  of 

corneal  wound 362 

PAGENSTECHEE.     (See  Ope- 
rations.) 

PANOPTHALMITIS 315 

Effect  on  Lens 168 

Clinical    History,    Causation, 

Symptoms 340,  342 

PATHOLOGY     of     Lenticular 

Cataract 75 

History  of 75 

Microscopical  changes 80 

PETIT'S  CANAL 47 

Operations,  value  of,  in  Sec- 
ondary Cataract 351,  369 

PETPIFACTION  OF  LENS.  . 

103,  201 


INDEX— C 

PAOF, 

I'lIAKJTTS— 
Duration,  Clinical  History  and 

Description  240.  339 

PHAK(VSrDKl?OM •?  I? 

PHOTOMETER  131 

PHTHISIS  BULBI— 

Clinical  History  and  Cause .  . . 

1G3,  340 
POLYOPIA  MONOCULAETS.   128 

PORES  in  CAPSULE 55 

PRESBYOPIA 17 

PRESSURE,    INTRACAPSU- 
LAR       97 

PURKINJE   ARTERIAL   pic- 
tures      130 

PURKINJE,  SANSON,  figures.  121 
Value  in  diagnosing  Aphakia.    373 

PUPIL  APHAKIC— 

Conditions  in 372 

Conditions  of.  in  cicatrization 

of  Iris  in  the  wound 330 

Occlusion  of 340 

Position  of  in  Secondary  Cat- 
aract   ' 341 

Seclusion  of 333,  341 

PUPIL— 

Value  of  consensual  reaction 
during  cataract  formation..  131 
REFRACTION,    INDEX     OF 

IN  THE  LENS 59 

Development    of  Myopia,    in 
cataract  formation GO,     61 

RETINA— 

Determination    of   perception 

of  light 132 

Importance  of 13 1 

RETROGRESSION,  PHYSIO- 
LOGICAL, of  the  Lens ....     31 
RESORPTION      OF      CATA- 
RACT— 

Spontaneous 262 

SYMPATHETIC      OPTHAT^ 

MIA 155,  315 


597 
ONTINUED. 

VMiK 

RIPE  CATARACT— 

Origin  of  expression 234 

RIPENING  OF  CATARACT.  .   264 

Senile  Sclerosis 17 

S F.AM 8— Definition  and   I'or- 

mation 21,  23,     25 

SKIN — Condition  during  cat- 
aract formation 326 

SOEMMERING'S  CRYSTAL- 
LINE PEARL 88,  98,  258 

STAAR— (See  Cataract.) 
ST  A  A  R-FIG  URE— Arrange- 
ment of  (Tri-star,  or  three 

rays)   ^:^.     '^^ 

Cause  of 24,     37 

Complicated  figure 34,     37 

Significance  of 24 

Types  '^-^ 

SCLERA— 

Rupture  and  Results 166 

STAPLYOMA,  Corneal 332 

(See  Cystoid  Cicatrization.) 

STAPHYLOMA— 

INTER-CALARE,due  to  Len< 

in  anterior  chamher K'3 

EfPect  on  Lens Ki'"^ 

STAPHYLOMATOUS    VESI- 
CLES— 

Treatment -^32 

STRABISMUS— 

(After  operations) 413 

SUBLIMATE— 

Use  in  operating 324 

SUBLUXATIO  LENTIS— 
Aetiology,   Prognosis,    Symp- 
toms, Treatment 158 

SUGAR  IN  AQUEOUS—. ...     71 

Tvcns,  Chemistry  of 67 

Vitreous 71 

SYMPATHETIC        IRRITA- 
TION     353 


598 

INDEX— C 

TAGE 

SYNCHISIS  CORPORIS  VIT- 
REI   t^,  151 

TEARS,  INDEX  OF  REFRAC- 
TION     375 

TEETH— 

Hutcliinsou,  Rachitic 191 

TE.MPERATURE       WITHIN 

THE  EYE-BALL 62 

THERAPEUTIC      Value      of 

Heat 63 

THERAPY  OF  DISEASES  OF 
THE  LENS— 

Medicinal 260 

Prophylactic 261 

Spontaneous 261 

TUMORS— 

Pathogenesis  of 102 

VACUOLES  in  the  Lens  Fibres.     82 
VASCULAR  CAPSULE  of  the 

Lens;   Importance  in   Mal- 
formations of  Lens  System.   138 
VESICLE,  Primary  Indenting..  141 

VESICULAR  CELLS— 

Genesis 85,  87,     98 

Retrogressive  changes.  ..  103,  246 

VISION— 

Age-advancing   248 

Acuity  of,  in  Aphakia 387 

Binocular,  in  Aphakia 412 

Cataractous  Remains 334 

Cicatrization  of  Iris  in  wound.  330 
Diminution  in  Aphakia.  .330, 

339,  348,  and 388 

Disturbances  of 123 

Glasses,  effect  of 405 

In  Aphakia 365 

In  Cataract 127,  130 

Piirtial  Cataract 124 


ONTINUED. 

PAGE 

VITREOUS— 

Action  in  Lens  Fibres 254 

Albumen  in 71 

Chemistry  of 69 

Destruction  of,  by  action  of 

foreign  bodies 161,  203,  285 

Detachment 311,  353 

Effect  on,  in  Reclination.286,  294 
Examination     of,     in     young 
Fluidity  of 151,  286 

children  213 

Infection  of 344 

Opacities    noted    in    cataract 

formation 205 

Prolapse  of,  in  Capsulotomie . .  309 

During  Operation.  165,  166,  314 

Historical  notes 315 

Refraction,  index  of 70,  374 

History  of 108 

Sugar  in 71 

VORTICES  LENTIS 35 

W^ATER— 

Amount  in  Normal  Lens.  .62,  63 
Amount  in  Cataractous  Lens . 

63,  8'^ 

WBDL'S  VESICULAR  CELLS,  87 

Characteristics 88 

Differentiation 40,  52,  59 

Genesis  and  development. ...  87 

WHORL 25 

ZONULA  ZINII— 

Anomalies  of  formation 74 

Atrophy  of 73 

Action  of  Aqueous  on 36 

Development  of 27.  'Id 

Elongation  and  Distention  .  .  .  15() 

Focal  Illumination 117 

Function  of 3(;,  18 

Genesis  of 47 


599 

INDEX— Continued. 

i'Ai;i;  VAi.i: 

Historical  T?evie\v 27        Scmicsciuh'  of 7)}.  lo3 

Hypertropliy  of 73  Tears  of — 

Influence  of,  on  Lens  fibres.  .      30  During  depres^sion 389 

Lcngtlieninp^  of,  Congenita!.  .    1(!3  ]\l('clianism  of 1-59,  108 

Malformation,  result  of 146  Partial 157,  158 

Origin  and  insertion  of 47  Tears  of  Zonula  et  Capsule...   251 

Pathology  of 73         Thickening  of 214 

Results  of 150,  154        Varieties  of  Fibres 48 

Solution  of  Continuity.  ...74, 
149,  and 151 


mm 


'  M.;JS 


5  ,  f>-if 


f"  t 


